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Margaret L. Godley, PhD, CBiol, MIBiol

Clinical Scientist, Honorary Fellow in Pediatric Urology,
Institute of Child Health, University College London and
Great Ormond Street Hospital for Children, London, United
Kingdom

This decision was based on the fact that defecation problems impact on our condence in the estimate of effect and may in infants <6 months old have different diagnostic considerations change the estimate blood pressure medication excessive sweating cheap 12.5 mg hydrochlorothiazide visa. The final draft of the guidelines was sent to all of the See the online-only appendix for the quality assessment of all committee members for approval in May 2013 blood pressure exercise program discount 25 mg hydrochlorothiazide with amex. Revision Consensus Meeting and Voting this guideline should be revised every 3 to 5 years blood pressure record proven 25mg hydrochlorothiazide. Three consensus meetings were held to achieve consensus on and formulate all of the recommendations: September 2012 hypertension 16070 order hydrochlorothiazide uk, February 2013, and May 2013. The group At present, the most widely accepted definitions for child anonymously voted on each recommendation. It was decided in advance been divided into 2 groups, based on the age of the patient. YesYes Refer to specialty 1 2 consultation 3 Evaluate NoNo YesYes after 2 weeks, treatment effective NoNo 30 YesYes 22 23 18 Treat accordingly YesYes YesYes YesYes 31 Colonic manometry Doubts about the diagnosis of Tailor testing for (Rule out colonic neuro constipation The role that constipation plays developmental age of at least 4 years and have insufficient criteria to in children with predominant abdominal pain is not clear. At least 1 episode of incontinence per week after the acquisition of toileting skills 3. History of large-diameter stools that may obstruct the toilet Accompanying symptoms may include irritability, decreased appetite, and/or early satiety, which may disappear immediately following passage of a large stool For a child with a developmental age! Parents (2) Based on expert opinion, the diagnosis of functional describe infants with dyschezia as straining for many minutes, constipation is based on history and physical examination. The symptoms persist for 10 to 20 minutes, until soft or liquid stools are passed. The symptoms begin in the first months of life and resolve spon taneously after a few weeks. In the absence of any scientific Question 2: What Are the Alarm Signs and literature evaluating this condition, infant dyschezia is not dis Symptoms That Suggest the Presence of an cussed in this document. Although those definitions are more inclusive, purported symptoms of constipation in infants and children are they probably encompass a more heterogeneous group of nonspecific. Constipation is also a prominent symptom in children who have the information should also be obtained regarding previous other underlying medical conditions such as prematurity, develop and present treatment. Ideally, based on expert opinion, a 3-day mental delay, or other organic diseases, but the present guideline is diary should be used to better evaluate dietary and fluid intake. Medication history should be collected, including the use of oral Given some evidence showing early treatment favorably laxatives, enemas, suppositories, herbal treatments, behavioral affects outcome, we decided to use as an entry point in the treatment, and other medications. Based on consensus, the group agreed that the 2-month peers, and temperament, is also relevant. Other Denitions Used in this Guideline Physical examination should specifically focus on the growth parameters, abdominal examination (muscle tone, distension, fecal Intractable Constipation: Constipation not responding to mass), inspection of the perianal region (anal position, stool present optimal conventional treatment for at least 3 months. Digital amount of stool on rectal examination or excessive stool in the distal rectal examination evaluates the presence of an anal stenosis or of a colon on abdominal radiography. Extreme fear during anal inspection the likelihood that that same result would be expected in a patient and/or fissures and hematomas in combination with a history of without functional constipation) of 1. A points of history and physical examination to guide in the evaluation diagnosis of constipation as made by the clinician was not defined. In conclusion, evidence does not support the use of digital (3) Based on expert opinion, we recommend using Tables 3, rectal examination to diagnose functional constipation. Five studies were included assessing the value of scoring fecal loading on abdominal radiogra Constipation in Children, What Is the phy in diagnosing clinically defined childhood constipation. Barr et al (26) was the first to develop an abdominal One study was included evaluating the value of digital rectal radiography score to diagnose functional constipation. The Barr examination in diagnosing clinically defined childhood consti scoring system ranges from 0 to 25, with a total score of >10, pation. Beckman et al (24) aimed to determine whether clinical indicating excessivefecalretention. Differential diagnoses of constipation in infants/toddlers and divided into 3 segments. Each segment is scored from 0 to 5, with a children/adolescents score range of 0 to 15. C ayan et al (30) rated fecal loading on abdominal radiogra Drugs, toxics phy defined by the Blethyn scoring method (31). Klijn et al (38) found a statistically significant Constipation starting extremely early in life (<1 mo) difference in mean rectal diameter between the constipated group Passage of meconium >48 h (4. Bilious vomiting In conclusion, evidence does not support the routine use Abnormal thyroid gland of rectal ultrasound to diagnose functional constipation. Sacral dimple Voting: 7, 8, 8, 8, 9, 9, 9, 9 Gluteal cleft deviation (5) Based on expert opinion, in the presence of alarm signs Extreme fear during anal inspection or symptoms or in patients with intractable constipation, Anal scars a digital examination of the anorectum is recommended to exclude underlying medical conditions. Voting: 7, 8, 8, 8, 8, 9, 9, 9 (6) the routine use of an abdominal radiograph to diagnose gastroenterology department. The choice for a case-control design in all studies may be used in a child in whom fecal impaction indicates that all results are at risk for serious bias. In all of the is suspected but in whom physical examination is studies, children with constipation were compared with healthy unreliable/not possible. This study design is likely to overestimate diagnostic (8) Colonic transit studies are not recommended to diagnose accuracy. In conclusion, evidence does not support the routine use Voting: 7, 8, 9, 9, 9, 9, 9, 9 of colonic transit studies to diagnose functional constipation. Bijos et al (35) calculated a rectopelvic ratio by dividing the transverse diameter of the rectal ampulla by the transverse Constipation to Diagnose an Underlying diameter of the pelvis. Milk) Allergy, Celiac Disease, Hypothyroidism, and In the study by Singh et al (36), the impression of the rectum Hypercalcemia Five of them fulfilled our median rectal crescent in children with constipation was 3. Cutoff values constipation has been vigorously debated since the study by Iacono for constipation were not presented. These studies were, however, performed in an allergy treatment, the rectal diameter of the children with constipation center, a fact that could have led to an overestimation of the Furthermore, the authors did not use the double-blind provocation test that is considered the gold stan (13) Based on expert opinion, we do not recommend dard method to diagnose allergy to a food antigen. A subsequent routine laboratory testing for hypothyroidism, celiac prospective study conducted by Simeone et al (41) in 91 patients disease, and hypercalcemia in children with consti affected by chronic constipation did not confirm this association. Voting: 7, 7, 7, 7, 8, 8, 9, 9 No published evidence met our inclusion criteria on the prevalence of hypothyroidism, celiac disease, and hypercalcemia in children with functional constipation. Question 5: Which of the Following Examinations Should Be Performed in Children 4. None of them fulfilled our sequence of relaxation of the external anal sphincter rather than the inclusion criteria. A total of 130 children with intractable constipation and 28 with nonretentive fecal incontinence (see 4.

Syndromes

Fabrics and clothing
Chronic kidney failure if both kidneys are involved (can progress to end-stage kidney disease)
Have you had surgery or radiation to your urinary or sexual organs?
Recent travel to a tropical region
Heart tumors (rhabdomyoma)
Numbness or tingling that spreads down an arm or leg
Excessive bleeding
Thyroplasty
Iron deficiency
Health care workers

Causes: A variety of bacteria may enter the lung by one of the following routes: 1 Through air passages due to bronchopneumonia or following inhalation of a foreign body arterial disease cheap hydrochlorothiazide 25mg otc. Clinical features: Malaise Fever Dyspnea Pain sometimes Hemoptysis Halitosis X-ray shows a fluid level arteria axilar buy hydrochlorothiazide overnight delivery. A doctor will test the patient and then decide when the patient is no longer dangerous blood pressure medication starting with v purchase 25mg hydrochlorothiazide free shipping. When the disease under medical treatment ulterior motive order hydrochlorothiazide australia, for 6 weeks, and changed from sputum positive to sputum negative. Abd El-Kader Associate Professor of Physical Therapy Diabetes Mellitus Introduction Functional Anatomy of the Endocrine Pancreas the pancreas is an elongated organ nestled next to the first part of the small intestine (figure 5). There are two important effects are: 1 Insulin facilitates entry of glucose into muscle, adipose and several other tissues. It should be noted that: there are some tissues that do not require insulin for efficient uptake of glucose: important examples are brain and the liver. In the absence of insulin, a bulk of the cells in the body become unable to take up glucose, and begin a switch to using alternative fuels like fatty acids for energy. Glycogen breakdown is stimulated not only by the absence of insulin but by the presence of glucagons, which is secreted when blood glucose levels fall below the normal range. Pathophysiology of diabetes mellitus: 1 Decrease glucose utilization> hyperglycemia (^blood glucose level), glucosuria (above 180%) leading to: a) Osmotic diuresis causing Polyuria. Types of diabetes the three main types of diabetes are type 1, type 2 and gestational diabetes. In addition high fiber helps in satisfying hunger, reducing high cholesterol and preventing constipation. If blood glucose -Less than 100 mg/dl before exercise, the person should eat a snake. Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. It is obviously caused by excess energy input over energy output, and consequently deposition of excess fat in the body. Epidemiology of Obesity 1 Age Obesity is often looked upon as a disease of middle age, but it can occur at any time of life. A high-risk waist circumference is defined as 35 inches (88 cm) or more for women and 40 inches (102 cm) or more for men. These methods are: (a) Underwater weighting For estimation of body fat, the subject exhales as much air as possible and then holds his breath and bends over at the waist. Researchers summarize that fat resists the low of electricity because it contains little water and few electrolytes such as potassium. So although it is still unclear what aspect of body physiology bioelectrical impedance analyzers are actually measuring, they do provide a rapid and fairly accurate measurement of the percentage of body fat (body fat analyzer). A truly motivated individual will generally stay on a diet for a long time, initially for weight loss and then for weight maintenance. To assist the circulation in the legs and thereby help to prevent post-operative venous thrombosis. The importance of maintaining adequate ventilation of the lungs by breathing exercises and the clearance of excess secretions from the airways must be explained. Reassurance should be given that breathing exercises, huffing, coughing and moving around in bed will do no harm to the stitches, drainage tubes or operation site. There are, however, some patients with severe mitral valve disease or long standing pulmonary hypertension that may have developed associated 48 chronic obstructive lung disease and assistance with removal of secretions is required. In the earlier stage of cardiac disease, the patient may have a persistent dry cough or expectorate frothy white sputum. But its action usually about 30%of the action of breathing in the first postoperative days. Post-operative treatment Day of operation If the patient is not on a ventilator, breathing exercises can be started on the day of the operation (provided the cardiovascular system is stable) as soon as he is conscious enough to co-operate. First and second day after operation Physiotherapy will probably be necessary four times during the day. Those who have been ventilated should also start breathing exercises once the endotracheal tube has been removed. The patient should be reminded to practice breathing exercises at least every hour whilst awake. Walking around the ward may be started as soon as the second or third post-operative day. After cardiac surgery, most patients find climbing stairs much less exhausting than pre operatively. Before discharge Thoracic expansion, shoulder mobility and posture should have returned to normal. The patient should continue breathing exercises for about 3 weeks following the operation, although he will probably be discharged after 10-14 days. Intubation (insertion of an endotracheal or nasogastric tube): a Irritates the mucosal lining of the tracheobronchial tree which causes an increase in mucus production. General inactivity and bed rest postoperatively: It causes secretions to pool, particularly in the posterior basilar segments of the lower lobes. Atelectasis Is incomplete expansion of the lung because of collapse of the alveoli. Chest tube inserted in the area of the 2 intercostal space to measure the pressure and withdrawal the accumulated gas or air. Pulmonary embolism: Is obstruction of a pulmonary artery or one of its branches by a clot arises from a deep veins. It can result from ventilation perfusion imbalance of underlying pulmonary disease or destruction of blood cells by the heart lung machine. Effective coughing: Cough should be effective with less pain so, the patient should support the incisional area and lean his trunk toward the area of incision. Cardiac tamponade: is a lin1itation of ventricular filling during diastole because of fluid collection within the pericardial sac. Deep venous thrombosis: Is a coagulation or clot of blood that remains at the site of origin, if it detaches the clot can travel to the right side of the heart and enter the lung called a pulmonary embolism. B In chronic cases: -Apply deep breathing exercise, -Active exercise and mobilization. Wound infection: Infected wound become hot, red and edematous the sutures tend to cut through the tissues and the wound may gape either along the whole length or in between the sutures. Physiotherapy: 1 Clean wound can receive superficial heat (as infrared), if it is a superficial wound a deep heat (as short wave), if the wound is deep. Treatment Surgical by open heart technique and the defect is closed by direct sutures or by using synthetic material as tiphlon or darcon. Massive pulmonary hypertension and as result Rt to Lt shunt (Eisenmengers syndrome). Treatment Surgical by closed heart technique (excision of the coarcitation segment and end to end anastomosis) 5. Palliative operation: In Severe cases with cyanotic attacks in age below one year. Rheumatic fever It is a widespread disease in lack of hygiene, malnutrition and overcrowdness. Left atrial fibrillation &loss of contractile element leads to thrombosis and stroke. Hemodynamics of Tricuspid and pulmonary valve affection They are rare to be affected by rheumatic fever, bust in most cases the affection is functional and not organic & in the form of stenosis. Congestive heart failure (both right and left side failure) Manifestations of right side heart failure 1. Each patient must be individually assessed to determine diagnosis, associated injuries, responses, and achievable goals. Patients and his family: Patients and his family must never be overlooked as members of prescribing team.

The autistic children displayed fewer joint attention behaviors than both of the comparison groups blood pressure healthy numbers discount 25 mg hydrochlorothiazide with amex. Language development was assessed initially and then at follow-up 13 months later using the Reynell Developmental Language Scales blood pressure wrist watch order hydrochlorothiazide 12.5 mg mastercard. Joint attention was a significant predictor of language development in the autistic group (r = 0 blood pressure medication used for anxiety cheap 12.5 mg hydrochlorothiazide. However blood pressure solutions buy 12.5 mg hydrochlorothiazide with amex, other studies have found that joint attention is unrelated to language development within children with autism. For example, Morgan, Maybery and Durkin (2003) examined 21 children with autism (mean age = 54 months) and 21 typically developing children (mean age = 55 months) on three measures of joint attention. In other words, joint attention and language development were independent (see also Loveland & Landry 1986; Stone & Yoder 2001). Emerging view of the role of language/communication impairments within autism An emerging view of the role of language and communication impairments within autism is that they overlap, perhaps considerably, with the language and communication impairments observed outside of autism. All three groups used personal pronouns most frequently, followed by demonstrative reference, and then comparative reference. A speech-language pathologist tested the children individually on 24 test sentences that the children were instructed to act out. In addition, when the language proficiency of the pro bands (z-scores of at or below 1. Twenty-six percent of the autistic parents reported a history of probable or definite language delay, articulation defects, trouble learning to read, or trouble spelling compared to 2 only 11% of the parents of the controls (c = 6. For example, Howlin (2003) examined the current linguistic functioning of 34 adults with autism with a history of childhood speech delay (assigned to the Autistic Disorder group; mea n age = 27. Eisenmajer, Prior, Leekam, Wing, Ong, Gould and Welham (1998) compared 46 children with autism (mean age= 11. Children with autism with a history of early language delay (no single words before 24 months and no use of phrases by 36 months) did not differ in current day autistic symptomotology from children with autism without a history of early language delay; however, the two groups did differ in their current day language skill. Thus, it was the language skill and not the autistic symptomotology that distinguished the two groups. Three of the four children, Fritz, Harro, and Ernst, each displayed three of the communication impairments listed under the diagnostic criteria for Autistic Disorder, including impaired ability to initiate/sustain conversations, stereotyped, repetitive, or idiosyncratic language, and social play below developmental level. The fourth child, Hellmuth, displayed stereotyped, repetitive, or idiosyncratic language, and social play below developmental level. Forty-two pediatric patients with a history of language, cognitive, social, and/or behavioral deterioration were selected for further examination. Five were identified with epileptiform discharges in the occipital region and were eliminated from further study. Autistic-like behavior was present at the first observation in four of the 11 children (36%). At the last observation, autistic-like behavior was still present in two of the children (18%). Of the 177 children with language regression, 155 had received an autism diagnosis. Children whose language regressed before 36 months had a higher probability of an eventual autism diagnosis (144 of 158 children; 91%) than children whose language regressed at 36 months or later (11 of 19; 58%). Additionally, an eventual autism diagnosis was more common in males (90%) with regressed language than in females (75%). Seizures were more common in children whose language regressed after 36 months (10 of 19; 53%) than children whose language regressed before 36 months (22 of 158; 14%). The overlap between autism and specific language delay With the exception of language regression, the recommended early markers "red flags" for autism and for specific language delay without autism are synonymous: "no single words by 18 months" and "no two word spontaneous (non-echoed) phrases by 24 months" (Baird, Cass, & Slonims 2003; Filipek, Accardo, Baranek, Cook, Dawson, Gordon, Gravel, Johnson, Kallen, Levy, Minshew, Prizant, Rapin, Rogers, Stone, Teplin, Tuchman, & Volkmar 1999). However, very few studies have examined the early language development of children with autism, and none has compared the early language development of children with autism with that of children with specific language delay. Additionally, nearly 75% of typically developing children at 1;4 name or label objects (Fenson et al. Finally, while the average number of words produced by typically developing children at 1;4 is 31 words, the mean number of words produced by the children with autism under the age of 2 years was only 7 words. Future directions and recommendations As previously mentioned, very few studies have looked at language development in very young children with autism; the few studies that have were focused on social cognition constructs. We suggest that it is imperative to investigate communication and language development as early as possible. Consider an analogy from Williams syndrome: Toddlers with Williams syndrome perform relatively poorly on a language task but relatively well on a numerosity task; adults with Williams syndrome show just the opposite pattern (Paterson, Brown, Gsidl, Johnson, & Karmiloff-Smith 1999). Thus, it could be injudicious to assume that outcomes observed in older children or adults characterize the starting states in early development. Even more rare than longitudinal studies are studies of young children with autism using psycho linguistic methodologies, even though such techniques have become commonplace in the study of non-autistic children with language impairment (Edwards & Lahey 1996; Gathercole & Baddeley 1990; Stark & Montgomery 1995). Most strikingly, to date there have been no comparisons between the early language development of young children with autism and the early language development of young children who are delayed in their language development but do not exhibit autistic behaviors. We recommend comparisons examining early lexical and grammatical development, the mechanisms and patterns of early word learning and vocabulary development, the relationship between lexical and grammatical development, and the relation between language level and verbal repetition behavior. We recommend investigating early lexical development because the mechanisms that support word learning have provided a rich basis of inquiry in typically developing populations (Bauer, Goldfield, & Reznick 2002; Dromi 1999; Hoff & Naigles 2002; Markson & Bloom 2001). Fast mapping has been examined in young children with typical language development (Behrend, Scofield, & Kleinknecht 2001; Heibeck & Markman 1987; Jaswal & Markman 200I; Wilkinson & Mazzitelli 2003), as well as children with Down syndrome (Chapman, Kay-Raining Bird, & Schwartz 1990), Williams syndrome (Stevens & Karmiloff-Smith 1997) and specific language impairment (Dollaghan 1987; Ellis Weismer & Hesketh 1996, 1998; Eyer, Leonard, Bedore, McGregor, Anderson, & Viescas 2002;Rice, Buhr, & Nemeth 1990). However, fast mapping has not been examined in young children with autism and very little is known about the early word learning processes that support lexical development in this population. Early grammatical development is of importance because it is posited to depend on lexical development, such that advances in grammar occur only after vocabulary has reached a critical mass (Bates & Goodman 2001; Marchman & Bates 1994). The link between lexical and grammatical skills in typical and atypical development is well documented (Dionne, Dale, Boivin, & Plomin 2003; Maitel, Dromi, Sagi, & Bornstein 2000; Throdardottir, Ellis Weismer, & Evans 2002); however, little is known about this link in autism. Finally, we recommend investigating verbal repetitions in the language use of young children with and without autism. That 75% figure can be traced to only one empirical study, which was conducted almost four decades ago with children diagnosed with infantile psychosis (Rutter, Greenfield, & Lockyer 1967). While it is true that 75% of the 34 children examined in that study exhibited verbal repetition at some point in their development, there was great variability in the pattern and frequency of the verbal repetition, and for the majority of the children, verbal repetition was not a continuing characteristic in later development (see also Wing 1971). Thus, an investigation of the verbal repetition exhibited by young children with and without autism is crucial for understanding verbal repetition phenomena. Examining the early language development of children with autism is of theoretical and practical significance. Of specific theoretical significance are the empirical tests of fundamental language development hypotheses, such as the critical mass hypothesis and the nature of the link between lexical and grammatical development in young children with autism. Of more general theoretical significance is whether the language delays and deficits observed in autism should be considered a unique phenomenon, or whether they overlap with other language and communication disorders. We can refer to these two possibilities as the distinct category account and the dimensional account. The dimensional versus categorical nature of psychopathological conditions such as social anhedonia, depression, and dissociation has been addressed in prior research (Blanchard, Gangestad, Brown, & Horan 2000; Ruscio & Ruscio 2000; Waller, Putnam, & Carlson 1996). We recommend exploring the overlap in the phenomena associated with language delays in young children with autism and late talkers without autism. Further research aimed at testing the language distinct account versus the language dimensional account should provide important implications about phenotypic markers (as suggested by Dawson, Webb, Schellenberg, Dager, Friedman, Aylward, & Richards 2002) and by extension, recommended treatment. Predicting language production in children and adolescents with Down syndrome: the role of comprehension. Genetic evidence for bidirectional effects of early lexical and grammatical development. Taxonometric analysis of specific language impairment in 3 and 4-year-old children. Genetics and Mental Retardation Syndromes: A new look at behavior and interventions. Antwerp Papers in Linguistics 102: Language acquisition in young children with a cochlear implant (pp. The Development of Aspect Markers in a Cantonese-speaking Child between the Ages of21 and 45 Months. First language acquisition after childhood differs from second language acquisition: the case of American Sign Language. Language and communication in mental retardation: Development, processes and intervention.

In addition blood pressure 5040 purchase hydrochlorothiazide 12.5mg otc, various studies have documented unusual aspects even of very early communication development in au tism (Ricks and Wing hypertension leg pain buy hydrochlorothiazide from india, 1975; Tager-Flusberg et al arteria iliaca communis buy hydrochlorothiazide 25mg fast delivery. In assessing language and communication skills blood pressure chart during the day buy discount hydrochlorothiazide online, parent interviews and checklists may be used, and specific assessment instruments for chil dren with autistic spectrum disorders have been developed (Sparrow, 1997). For children under age 3, scores on standardized tests may be particularly affected by difficulties in assessment and by the need to rely on parent reports and checklists. There are also several standardized instruments that provide useful information on the communication and language de velopment of preverbal children with autism; these include the Commu nication and Symbolic Behavior Scales, the Mullen Scales of Early Learn ing, and the MacArthur Communicative Development Inventory. For children with some verbal ability, social and play behaviors are still im portant in terms of clinical observation but various standardized instru ments are available as well, particularly when a child exhibits multiword utterances. Areas to be assessed include receptive and expressive vo cabulary, expressive language and comprehension, syntax, semantic rela tions, morphology, pragmatics, articulation, and prosody. The choice of specific instruments for language-communication as sessment will depend on the developmental levels and chronological age of the child. As with other aspects of assessment, an evalua tor should be flexible and knowledgeable about the particular concerns related to assessment of children with autism. Motor abilities in autism may, at least in the first years of life, repre sent an area of relative strength for a child, but as time goes on, the development of motor skills in both the gross and fine motor areas may be compromised, and motor problems are frequently seen in young chil dren with autism. Evaluations by occupational and physical therapists are often needed to document areas of need and in the development of an intervention program (Jones and Prior, 1985; Hughes, 1996). Standard ized tests of fine and gross motor development and a qualitative assess ment of other aspects of sensory and motor development, performed by a professional in motor development, may be helpful in educational plan ning. The education of physicians, nurses, and others regarding warning signs for autistic spectrum disorders is very important. After initial referral for assessment and diagnosis, consultations with other medical professionals may be indicated, depending on the context (Filipek et al. When this consulta tion is relevant to the educational program, reimbursement may appro priately be made by the local education authority. The available literature has clearly documented that children with autism are at risk for developing seizure disorders throughout the devel opmental period (Deykin and MacMahon, 1979; Volkmar and Nelson, 1990). Seizure disorders in autism are of various types and may some times present in unusual ways. Certain fea tures, such as the abrupt behavioral and developmental deterioration of a child who was previously developing normally, may suggest the impor tance of extensive medical investigations (Volkmar et al. In some cases, the use of psychotropic medications may be indicated for young children (see Chapter 10). Although not curative, such medica tions may help to reduce levels of associated maladaptive behaviors and help children profit from educational programming. The use of such agents requires careful consideration of potential benefits and risks and the active involvement of parents and school staff (see Volkmar et al. As for all children, an intervention program must be individualized and tailored to the specific needs, strengths, and weak nesses of the individual child. In addition, children with autistic spec trum disorders often present special challenges for intervention. Social interaction requires careful attention to multiple, shift ing strands of information; an ability to perceive the thoughts, feelings, and intentions of others; and coping with novel situations on a regular basis. In children with autistic spectrum disorders, social difficulties per sist over time, although the nature of the social difficulties may change with age and intervention (Siegel et al. These social difficulties, as reflected in relationships with teachers and particularly in relationships with peers, are different from those seen in all other developmental disor ders and present special difficulties for programming. For a child with an autistic spectrum disorder to be able to be included in mainstream set tings, the child must be able to manage social experiences. While children with an autistic spectrum disorder can be served within many school environ ments, even for more cognitively able individuals this can be a challenge. The characteristic difficulties in social interaction require special teacher training and support beyond knowledge concerning general developmen tal delays or other learning disabilities. Often they are the first people to recognize a developmen tal problem, and they must pursue their concern until they receive a satisfactory diagnosis and find or develop appropriate services for their child. These many demands on parents occur in the context of family life, including the needs of other children, the parents as individuals and as a couple, and family needs as a whole. Most families cope effectively with these demands, but some may encounter very substantial stress as they raise their child with autism. In the 1950s and 1960s the psychodynamic explanation of autism held sway in the United States (Bettelheim, 1974). That perspective, now clearly counter to a large body of research on the biological roots of au tism, had important implications for treatment. We recognize that parents are partners in an educational process that requires close collaboration between home and school. In order to provide an appropriate education for their child, parents of children with autism need specialized knowledge and skills and scien tifically based information about autism and its treatment. Parents also need to be familiar with special education law and regulations, needed and available services, and how to negotiate on be half of their child. In addition, some parents need help coping with the emotional stress that can follow from having a child with a significant developmental disorder. However, it is a role that is not without costs, and the implications for family life are consider able. These include serving as teacher and advocate as well as loving parent and family member. Gallagher (1992) points out the complex demands this places on parents and the need to support family decision making and control, while providing sufficient professional expertise to enable their choices. Research suggests that while many families cope well with these de mands, the education of a child with autism can be a source of consider able stress for some families (see. In general, mothers report more stress than do fathers, often describing is sues related to time demands and personal sacrifice. Mothers of children with autism also report more stress in their lives than do mothers of children with other disabilities. Fathers of children with autism or Down syndrome report more dis ruption of planning family events and a greater demand on family fi nances than do fathers whose children are developing typically. These three groups of men do not differ, however, on measures of perceived competence as a parent, marital satisfaction, or social support (Rodrigue et al. The time spent working with a child with autism is sometimes stress ful and demanding, but it also has the potential to reduce family distress and enhance the quality of life for the entire family including the child with autism (Gallagher, 1991).