Mr. Paul A. Banaszkiewicz FRCS (Glas) FRCS (Ed)

• FRCS (Eng) FRCS (Tr & Orth) Cert Clin Ed
• Queen Elizabeth Hospital
• Gateshead, UK

Males and their sexual partners may differ in their perception of what constitutes an acceptable ejaculatory latency anxiety disorder buy buspar 10mg with amex. There may be increasing concerns in females about early ejaculation in their sexual partners anxiety blog buy 5 mg buspar otc, which may be a reflection of changing societal attitudes concerning female sexual activity anxiety symptoms peeing discount buspar 10mg on line. Diagnostic iViarlcers Ejaculatory latency is usually monitored in research settings by the sexual partner utilizing a timing device anxiety and nausea cheap buspar 5mg overnight delivery. For vaginal intercourse anxiety symptoms or heart problems buy 10mg buspar with visa, the time between intravaginal penetration and ejaculation is measured anxiety symptoms cold hands order genuine buspar on line. Functional Consequences of Prem ature (Eariy) Ejaculation A pattern of premature (early) ejaculation may be associated with decreased self-esteem, a sense of lack of control, and adverse consequences for partner relationships. It may also cause personal distress in the sexual partner and decreased sexual satisfaction in the sexual partner. Ejaculation prior to penetration may be associated with difficulties in conception. When problems with premature ejaculation are due exclusively to substance use, intoxication, or withdrawal, substance/ medication-induced sexual dysfunction should be diagnosed. It is necessary to identify males with normal ejaculatory latencies who desire longer ejaculatory latencies and males who have episodic premature (early) ejaculation. Neither of these situations would lead to a diagnosis of premature (early) ejaculation, even though these situations may be distressing to some males. Comorbidity Premature (early) ejaculation may be associated with erectile problems. In many cases, it may be difficult to determine which difficulty preceded the other. Lifelong premature (early) ejaculation may be associated with certain anxiety disorders. Acquired premature (early) ejaculation may be associated with prostatitis, thyroid disease, or drug withdrawal. A clinically significant disturbance insexual function is predominant inthe clinical picture. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. The disturbance is not better explained by a sexual dysfunction that is not substance/ medication-induced. Note: this diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention. With onset during withdrawai: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal. Specify current severity: Mild: Occurs on 25%-50% of occasions of sexual activity. For example, in the case of erectile dysfunction occurring during intoxication in a man with a severe alcohol use disorder, the diagnosis is 291. When more than one substance is judged to play a significant role in the development of the sexual dysfunction, each should be listed separately. The name of the substance/medication-induced sexual dysfunction begins with the specific substance. When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced sexual dysfunction, followed by the specification of onset. When more than one substance is judged to play a significant role in the development of the sexual dysfunction, each should be listed separately. Diagnostic Features the major feature is a disturbance in sexual function that has a temporal relationship with substance/medication initiation, dose increase, or substance/medication discontinuation. Certain agents, such as bupropion and mirtazapine, appear not to be associated with sexual side effects. The sexual problems associated with antipsychotic drugs, including problems with sexual desire, erection, lubrication, ejaculation, or orgasm, have occurred with typical as well as atypical agents. Although the effects of mood stabilizers on sexual function are unclear, it is possible that lithium and anticonvulsants, with the possible exception of lamotrigine, have adverse effects on sexual desire. Many nonpsychiatric medications, such as cardiovascular, cytotoxic, gastrointestinal, and hormonal agents, are associated with disturbances in sexual function. Sexual dysfunctions are also seen in individuals receiving methadone but are seldom reported by patients receiving buprenoflhine. Chronic alcohol abuse and chronic nicotine abuse are associated with erectile problems. Prevalence the prevalence and the incidence of substance/medication-induced sexual dysfunction are unclear, likely because of underreporting of treatment-emergent sexual side effects. Data on substance/medication-induced sexual dysfunction typically concern the effects of antidepressant drugs. Approximately 25%-80% of individuals taking monoamine oxidase inhibitors, tricyclic antidepressants, serotonergic antidepressants, and combined serotonergic-adrenergic antidepressants report sexual side effects. Approximately 50% of individuals taking antipsychotic medications will experience adverse sexual side effects, including problems with sexual desire, erection, lubrication, ejaculation, or orgasm. The incidence of these side effects among different antipsychotic agents is unclear. Exact prevalence and incidence of sexual dysfunctions among users of nonpsychiatric medications such as cardiovascular, cytotoxic, gastrointestinal, and hormonal agents are unknown. Elevated rates of sexual dysfunction have been reported with methadone or high-dose opioid drugs for pain. The prevalence of sexual problems appears related to chronic drug abuse and appears higher in individuals who abuse heroin (approximately 60%-70%) than in individuals who abuse amphetamines or 3,4-methylenedioxymethamphetamine. Chronic alcohol abuse and chronic nicotine abuse are related to higher rates of erectile problems. Development and Course the onset of antidepressant-induced sexual dysfunction may be as early as 8 days after the agent is first taken. In some cases, serotonin reuptake inhibitor-induced sexual dysfunction may persist after the agent is discontinued. There is some evidence that disturbances in sexual function related to substance/medication use increase with age. Culture-R elated Diagnostic Issues There may be an interaction among cultural factors, the influence of medications on sexual functioning, and the response of the individual to those changes. Gender-Related Diagnostic Issues Some gender differences in sexual side effects may exist. Functional Consequences of Substance/M edication-Induced Sexual Dysfunction Medication-induced sexual dysfunction may result in medication noncompliance. Many mental conditions, such as depressive, bipolar, anxiety, and psychotic disorders, are associated with disturbances of sexual function. The area of sex and gender is highly controversial and has led to a proliferation of terms whose meanings vary over time and within and between disciplines. An additional source of confusion is that in English "sex" connotes both male/female and sexuality. In this chapter, sex and sexual refer to the biological indicators of male and female (understood in the context of reproductive capacity), such as in sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia. The need to introduce the term gender arose with the realization that for individuals with conflicting or ambiguous biological indicators of sex. Transsexual denotes an individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital surgery (sex reassignment surgery). The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. A strong desire for the primary and/or secondary sex characteristics of the other gender. The condition is associated with clinically significant distress or impairment in social, occupationali^or other important areas of functioning.

Recording the to address current understanding of the technical issues of occurrence of illness in a facility and the response to the illcontagion and other health risks papa roach anxiety purchase buspar visa. This plan should include: ness characterizes and defnes the frequency of the illness anxiety nursing interventions buy buspar 10 mg with amex, a) Policies and procedures for urgent and emergency suggests whether an outbreak has occurred anxiety disorder purchase on line buspar, may suggest care; an effective intervention anxiety rings cheap buspar 10 mg visa, and provides documentation for b) Admission and inclusion/exclusion policies; administrative purposes anxiety 120 bpm generic buspar 5 mg mastercard. Managing Infectious Diseases in Child Care and as to protect the health of other children and staff; Schools anxiety symptoms jittery purchase buspar amex, 2nd Ed. This publication includes detailed handouts special health care needs; that can be used to inform parents/guardians and outline e) A procedure for documenting the name of person guidelines and rationale for exclusion, return to care and affected, date and time of illness, a description of notifcation of public health authorities. Other helpful refersymptoms, the response of the caregiver/teacher ences include Model Child Care Health Policies, available at or other staff to these symptoms, who was notifed. Curriculum for Managing Infectious Disg) Seasonal and pandemic infuenza policy; eases, an online training module for caregivers/teachers is h) Staff illness-guidelines for exclusion and re-entry. Managing infectious health problems or may develop health problems diseases in child care and schools: A quick reference guide. All prevention, early detection of remediable problems, and notifable diseases should be reported to the health departplanning for adaptations needed so that all children can ment. When age-appropriate health assessresponsible health authority to whom confrmed or suspectments and use of health insurance benefts are promoted ed cases of these diseases, or outbreaks of other infectious by caregivers/teachers, children enrolled in child care will diseases, should be reported, and should designate a staff have increased access to immunizations and other prevenmember as responsible for reporting the disease. Facility staff should encourage parents/ preventive health services that ensure they are healthy and guardians to schedule these preventive health services in a ready to learn. Updates of and other children whom the unimmunized child would the health record should be maintained according to the expose to increased risk of vaccine-preventable disease. Often 355 Chapter 9: Administration Caring for Our Children: National Health and Safety Performance Standards appointments for well-child care must be scheduled several should receive written notice of exclusion if noncompliance weeks in advance. If more than one immunizaity should obtain a health history report from the parents/ tion is needed in a series, time should be allowed for the guardians and documentation of an appointment for routine immunizations to be obtained at the appropriate intervals. The child should the federal McKinney-Vento Homeless Assistance Act for receive immunizations on admission or provide evidence of children experiencing homelessness are documented and an immunization plan to prevent an increased exposure to include a plan for obtaining available documents within a vaccine-preventable diseases. Immunizations should be required for all children educational materials, and on-site visits for education and in child care and early education settings. A copy of a form to use consider the consequences if they accept responsibility for for documentation of routine health supervision services is exposing a child who cannot be fully immunized (because of available from Model Child Care Health Policies at immaturity) to an unimmunized child who may bring disease Bright When a child who has a medical exemption from immunizafutures: Guidelines for health supervision of infants, children, and tion is included in child care, reasonable accommodation adolescents. Department of Health and Human Services, Centers for mandated immunization requirements and exemptions. The parent/guardian provider, his or her medical home, and other specialty health care professionals. The parent/guardian should provide Chapter 9: Administration 356 Caring for Our Children: National Health and Safety Performance Standards written consent to enable the caregiver/teacher to establish Standard 3. The family should Needs always be informed prior to the use of the permission unless Standards 9. Bright documentation of the services rendered provided by futures: Guidelines for health supervision of infants, children, and the special therapist; adolescents. A review of the medication on a regular basis or have emergency evidence for the medical home for children with special health care medications for specifc conditions. Stategies for in the medical care of the child but also involved in supportintegrating developmental services and promoting medical homes. The dental home: A child care and health care professionals is inadequate comprimary care concept. The person at the child care facility who is responsible for Every child should have a medical home and those with planning care for the child with special therapies or treatspecial health care needs may have additional specialists ments should obtain an individualized care plan, developed and therapists (4-7). Therathe location of the hospital emergency room departments pies and treatments need to meet the criteria for evidenced nearest to their home and child care facility. They also release an inMedicines can be crucial to the health and wellness of chilformation form at ucsfchildcarehealth. Parents/guardians should always be notifed in every instance when medication is used. Medications e) the process of accepting medication from parents/ the facility should have a written policy for the administraguardians. Parents/guardians 3) Controlled substances; and prescribing health professionals must give a caregiver/ 4) Expired medications; teacher written authorization to administer medication to 5) A policy to insure confdentiality; the child (12). Caregivers/teachers must be diligent in their 6) Storing and preparing distribution in a quiet area adherence to the medication administration policy and completely out of access to children; procedures to prevent any inadvertent medication errors, 7) Keeping all medication at all times totally which may be harmful to the child (11). Because g) the procedures to follow when administering children twenty-four months of age and younger are in a medications. These should include: period of rapid development and are more vulnerable to the 1) Assigning administration only to an adequately possible side effects of medications, extra care should be trained, designated staff; given to the circumstances under which medications will be 2) Checking the written consent form; administered to this population. For these reasons route, and documentation) (1); caregivers/teachers need to be aware of each of the medi4) Documenting and reporting any medication errors; cations a child received at child care as well as at home. Even common drugs such as 1) An accurate account of controlled substances acetaminophen and ibuprofen can result in signifcant toxicbeing administered and the amount being returned ity for infants and small children. Inaccurate dosing from to the family; the use of inaccurate measuring tools can result in illness or 2) When disposing of unused medication, the even death (2,3). These products are not safe for infants and young children and were withdrawn by the Consumer A medication administration record should be maintained on Healthcare Products Association for children less than two an ongoing basis by designated staff and should include the years of age in 2007 (4-6,8). The medication errors log can be reviewed and will point out what kind of intervention, if any, will be helpful in reducing the number 359 Chapter 9: Administration Caring for Our Children: National Health and Safety Performance Standards of medication errors. Controlled substances include narcotic pain mediand cold medicine use in children. Child care facilities must comply with the Americans administration in day care centers for children. An example of when medication Procedures cannot be returned is when a parent/guardian has removed the child care facility should have written sanitation policies the child from care and the facility cannot reach the parent/ and procedures for the following items: guardian to return the medication. If they b) Maintaining diaper changing areas and equipment in are given at home, the caregiver/teacher should be aware of a sanitary condition; their use and possible side effects. Healthy futures: practices, have demonstrated evidence of fecal contaminaMedication administration in early education and child care settings. Policy statement: Guidance for the administration of of diseases in child care settings (1). Posted signs provide frequent reminders to staff and c) Food procurement and storage; orientation for new staff. Education of caregivers/teachers d) Menu and meal planning; regarding handwashing, cleaning, and other sanitation proe) Food preparation and service; cedures can reduce the occurrence of illness in the group of f) Kitchen and meal service staffng; children with whom they work (2). Since many infected people carry communicable diseases A nutritionist/registered dietitian and a food service expert without symptoms, and many are contagious before they should provide input for and facilitate the development and experience a symptom, caregivers/teachers need to protect implementation of a written nutrition plan for the early care themselves and the children they serve by carrying out, on a and education facility. Outbreaks of foodborne illness have occurred in many settings, including child For sample policies see the Nemours Health and Prevention care facilities. Hand-washing and A policy about infant feeding should be developed with the diapering equipment reduces disease among children in out-ofinput and approval from the nutritionist/registered dietitian home child care centers. To what extent including blenders, feeding bottles, and food is the protective effect of breastfeeding on future overweight warmers; explained by decreased maternal feeding restrictionfl Evening and nighttime child care requires child (policy acknowledges that feeding infants on special attention to sleep routines, safe sleep environment, cue rather than on a schedule may help prevent supervision of sleeping children, and personal care routines, obesity) (1,2); including bathing and tooth brushing. Nighttime child care j) Introduction and feeding of age-appropriate solid must meet the nutritional needs of the children and address foods (complementary foods); morning personal care routines such as toileting/diapering, k) Specifcation of the number of children who can be hygiene, and dressing for the day. Children and staff must fed by one adult at one time; be familiar with evacuation procedures in case a natural or l) Handling of food intolerance or allergies. Eating behaviors of young child: h) Early identifcation of tooth decay; Prenatal and postnatal infuences on healthy eating, 59-93. Clinical could include information on the health risks and dangers guideline on periodicity of examination, preventive dental services, of these prohibited substances and referrals to services for anticipatory guidance, and oral treatment for children. The entire home should be kept smoke-free at all Toxic Substances times to prevent exposure of the children who are cared for Facilities should have written policies addressing the use in these spaces. Beliefs about the health effects prohibited in any vehicles that transport children. Smoke-free homes and substances referred to above is prohibited during all times cars program. Centers should have a written policy prohibiting frearms, Child care centers and large family child care homes should ammunition, and ammunition supplies. The hazards of second-hand and third-hand smoke expoFor large and small family homes the policy should include sure warrant the prohibition of smoking in proximity of child that ammunition and ammunition supplies should be: care areas at any time. The residue includes heavy metParents/guardians should be notifed that frearms and other als, carcinogens, and even radioactive materials that young weapons are on the premises. These items can trigger asthma and allergies when the children do use should not be accessible to children in a facility (2,3). American Academy of Pediatrics, Committee on Injury and c) Suspected sexual, physical, or emotional abuse of Poison Prevention. Policy statement: Firearm-related injuries staff, volunteers, or family members occurring while affecting the pediatric population. Outcomes in children and young d) Injuries to children requiring medical or dental care; adults who are hospitalized for frearms-related injuries. Gun storage f) Mental health emergencies; practices and risk of youth suicide and unintentional frearm injuries. These the following procedures, at a minimum, should be adchanges are best known to health professionals who stay in dressed in the plan for urgent care: touch with sources of updated information and can suga) Provision for a caregiver/teacher to accompany a gest how the new information applies to the operation of the child to a source of urgent care and remain with the child care program (1,2). For example, when the information child until the parent/guardian assumes responsibility on the importance of back-positioning for putting infants for the child; down to sleep became available, it needed to be added to b) Provision for the caregiver/teacher to provide the child care policies. Frequent changes in recommended immedical care personnel with an authorization form munization schedules offer another example of the need for signed by the parent/guardian for emergency medical review and modifcation of health policies. A written plan provides the lowing types of incidents, at a minimum, that occur at the opportunity to prepare and to prevent poor judgments made child care facility should be addressed in the plan: under the stress of an emergency. Chapter 9: Administration 364 Caring for Our Children: National Health and Safety Performance Standards Unannounced mock situations used as drills can help ease Standard 3. Child care providers get lessons in Lee County the response to any situation in which exposure to bodily on being prepared. Facilities must have a plan for what to do employment and yearly thereafter in the facility to ensure in such situations (1-3). The Emergency MediIn the event that there is an urgent medical care or threatencal Services for Children National Resource Center ing incident, the facility should plan to review the process This site also lists internet links to emershould cover emergency care needs and be shared with gency plans for specifc health needs such as diabetes, and discussed between parents/guardians and caregivers/ asthma, seizures, and allergic reactions. Such an approach requires writFacilities should develop and institute measures to control ten plans, policies, procedures, and record-keeping so access of a threatening individual to the facility and the that there is consistency over time and across staff and an means of alerting others in the facility as well as summoning understanding between parents/guardians and caregivers/ the police if such an event occurs. Policy statement: Emergency provide shelter and related services); preparedness for children with special health care needs.

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It seems not unlikely that a number of individuals who become literally murderous towards a parent are to be understood as having become so in reaction to threats of desertion that have been repeated relentlessly over many years anxiety 2020 episodes discount generic buspar uk. For example anxiety symptoms while driving cheap 10 mg buspar otc, in an early paper that calls attention to the traumatic effects of separation anxiety symptoms ringing in ears purchase buspar 5 mg otc, Kestenberg (1943) describes a girl of thirteen who had been deserted by her parents and who had been cared for by a succession of other people anxiety tattoos purchase buspar paypal. During the course of treatment this girl pictured herself as grown up and so able to revenge herself on her mother by killing her anxiety jealousy generic buspar 10 mg amex. Many analysts who have treated patients with this type of background could give similar examples anxiety symptoms for hours buy buspar 10mg free shipping. These admittedly are no more than clinical anecdotes, and no adequate history of previous family relationships is given for any case. Furthermore, so far as is known, no researcher since Stott has made a systematic study to test a possible causal link between violent anger directed towards an attachment figure and a history of being subjected by that figure to repeated threats of being abandoned. At present, therefore, the suggested link is hardly more than a conjecture; but as a lead for research it seems promising. In recent years Hansburg (1972), by taking as his starting-point certain measures of how a person responds to separation, has begun to put this onto a more systematic footing. The clinical test Hansburg is developing comprises a dozen pictures, all but three of which depict a situation in which either a child is leaving his parents or a parent is leaving his child. Some of the situations, such as a child leaving to go to school or mother leaving her child at bedtime, are of a kind that any child of over six would be expected to take in his stride. Under each picture is written a title making explicit what the picture represents. In its present form the test is suitable for children and young adolescents in the age-range ten to fifteen years. Hansburg reports that, despite the upsetting nature of some of the scenes, administering the test has not created difficulties. Should the test prove as useful as it promises to be, versions suitable for -251younger children and also for older adolescents and adults could readily be designed. Although for each picture the seventeen statements are phrased a little differently, the range of feelings described is similar. Preliminary findings show, among other things, that children growing up in stable families give two or three times as many responses that express distress and concern at what is happening as responses that express anger and blame. By contrast, disturbed children who have experienced long and/or repeated separations, many of whom come from rejecting families, give at least as many angry and fault-finding responses as they do responses expressing distress and concern. Another interesting difference of balance, also seen especially in response to pictures representing a major disruption, is in the proportion of responses that indicate that the child will do his best to get along on his own or that he will be happier as a result of the event. While these form only a small minority of the responses given by children from stable homes, they are much in evidence in the responses of children who have experienced long and repeated separations or who come from -252unhappy homes. Some characteristics of persons who, by contrast, show a stable autonomy, and the conditions in which such autonomy develops, are the subject of Chapter 21. Each is directed towards the attachment figure: anxious attachment is to retain maximum accessibility to the attachment figure; anger is both a reproach at what has happened and a deterrent against its happening again. Thus, love, anxiety, and anger, and sometimes hatred, come to be aroused by one and the same person. That a single type of experience should arouse both anxiety and anger need cause no surprise. At the end of Chapter 8 it is pointed out that students of animal behaviour have observed that in certain situations either form of behaviour may be aroused and that whether an animal responds with attack or withdrawal, or with a combination of both, depends on a variety of factors that have the effect of tipping the balance either one way or the other. Between anxious attachment and angry attachment an analogous type of balance appears to obtain. A child who at one moment is furiously angry with a parent may at the next be seeking reassurance and comfort from that same parent. In the more violent type of tantrum, such as that which resulted when we -253Psychoanalysts have for long been especially interested in the interrelationships of love, fear, and hate, since in clinical work it is common to find patients whose emotional problems seem to spring from a tendency to respond towards their attachment figure with a turbulent combination of all three: intense possessiveness, intense anxiety, and intense anger. To account for the intimate connections found between attachment, anxiety, and anger, a number of hypotheses have been advanced. Among leading analysts who have regarded ambivalence to a loved figure as a key issue in psychopathology and have proposed solutions, Fairbairn (1952) advocates a frustration-aggression type of hypothesis; while Melanie Klein (1932; 1948b) holds that all aggressive feeling and behaviour is an expression of a death instinct that wells up within and must be directed outwards. The clinical phenomenon to which Klein drew especial attention during the 1920s and 1930s is that some children who are attached to mother with unusual intensity are, paradoxically, possessed of strong unconscious hostility also directed towards her. In their play they may express much violence towards a mother figure and then become concerned and anxious lest they have destroyed or alienated mother herself. Often after an outburst a child runs from the analytic room, not only for fear ran away faster than Gua could follow, she seemed to become "blind with fear" and would utter a series of shrill vibrant screams. In their discussion, the Kelloggs are in doubt whether to regard the tantrum as expressing rage or fear. Observations of this kind are now amply confirmed; and much other evidence demonstrates without doubt that the presence of hostile impulses, whether conscious or unconscious, directed towards a loved figure can greatly increase anxiety. It must, however, be remembered that just as hostility directed towards a loved figure can increase anxiety, so can being anxious, especially that an attachment figure may be inaccessible or unresponsive when wanted, increase hostility. It is of both great theoretical and great practical importance to determine how these vicious circles begin. Does increased anxiety precede increased hostility, is it the other way round, or do they spring from a common sourcefl When looking backwards from data provided by a patient in analysis it is notoriously difficult to unravel the sequence, as Ernest Jones noted many years ago (Jones 1929); and this difficulty holds no less during the treatment of young children than it does for older patients. Neglect of this methodological difficulty and insufficient attention to family relationships have, it is held, led Klein to one-sided conclusions. Logically it is clearly possible for intense anxiety to precede intense hostility in some cases, for the sequence to be reversed in others, and for them to spring from a single source and so be coincidental in yet a third group. Instead, her basic tenet is that increased anxiety is always both preceded by and caused by increased hostility; that anxiety may sometimes be independent of, sometimes itself provoke, and often be aroused by the same situation as, increased hostility is not conceded. Fairbairn addresses himself to the same clinical problem as Klein but proposes a very different solution. In the absence of frustration, he holds, an infant would not direct 196 aggression against his loved object. Anger and hostility directed towards an attachment figure, whether by a child or an adult, can be understood best, it is held, as being in response to frustration. But there is reason to believe that the motivational systems with which this work is concerned, namely those mediating attachment behaviour, are those affected in a very large proportion of the most severe and persisting cases of frustration, especially when the agent of frustration is, wittingly or unwittingly, the attachment figure himself/herself. The reason that anxiety about and hostility towards an attachment figure are so habitually found together, it is therefore concluded, is because both types of response are aroused by the same class of situation; and, to a lesser degree, because, once intensely aroused, each response tends to aggravate the other. As a result, following experiences of repeated separation or threats of separation, it is common for a person to develop intensely anxious and possessive attachment behaviour simultaneously with bitter anger directed against the attachment figure. Because of the tendency for anger and hostility directed towards a loved person to be repressed and/or redirected elsewhere (displaced), and also for anger to be attributed to others instead of to the self (projected), and for other reasons too, the pattern and balance of responses directed towards an attachment figure can become greatly distorted and tangled. Furthermore, because models of attachment figures and expectations about their behaviour are built up during the years of childhood and tend thenceforward to remain unchanged, the behaviour of a person today may be explicable in terms, not of his present situation, but of his experiences many years earlier. Children tell little more than animals, for what comes to them they accept as eternally established. Evidence regarding the nature of the experiences that lead to increased susceptibility to fear is considered in Chapters 15 and 16. In this chapter and the next the potential usefulness of the theory is illustrated by applying it to certain clinical syndromes in which overt anxiety and fear are prominent. Andrews 1966; Marks 1969), includes a broad range of conditions in which anxiety and fear are the main symptoms. Although when the condition is of recent onset some patients -258so labelled respond to fairly simple therapy. A majority of those whose condition has been present for a long time, it is now agreed, suffer also from a wide variety of other emotional troubles. Most are timid individuals prone not only to fear situations of many kinds but to become depressed, and apt to develop various psychosomatic symptoms as well. In all such cases the feature to which the term phobia is applied, for example fear of school (school phobia) and of crowded places (agoraphobia), is found to be only a small, and sometimes even negligible, part of a deep-seated disturbance of personality that has been present for many years. There is, however, a small minority of long-standing cases of phobia that appear to be very different. The individuals concerned, to whom Marks (1969) has drawn attention, are intensely afraid of some particular animal but, in all other respects, are stable personalities not given to psychological disturbance. Marks presents evidence that, in regard to personality functioning and psychophysiological responses, these individuals not only resemble people 198 who are psychiatrically healthy but differ markedly from those diagnosed agoraphobic. Whereas agoraphobic symptoms usually appear after the age of ten years, a specific and limited animal phobia has usually been present since before the age of seven years. The specific phobia appears to be due to the persistence into later life of the tendency to fear animals that is found commonly during the early years of childhood but usually diminishes to moderate or negligible proportions before or during adolescence. Discussion here concentrates on the majority group, namely people who suffer from deepseated disturbances of personality. The minority group, comprising people who suffer from specific animal phobias, probably present a different type of problem and are touched on only briefly. In what follows the term phobia is used only because so much of the descriptive material with which we are concerned is to be found in the literature under that head. It is placed in quotation marks in the chapter title in order to indicate a belief that, when applied to patients in the majority group, it is being misapplied. Others also have held that many of the cases commonly labelled phobic are mislabelled. Snaith (1968) similarly argues that agoraphobia -259is best regarded as a pseudophobia (although he uses the term in a way different from Brun). In the present work it is argued that not only is agoraphobia best regarded as a pseudophobia but so also is school phobia. By contrast, intense fear of a specific animal or of some other discrete situation in a person of otherwise healthy personality can sometimes be regarded as a case of true phobia. The distinction between the two conditions is readily defined in terms of the present theory. In the case of a phobic person, what is most feared is the presence of some situation that other people find much less frightening but that he either takes great pains to avoid or else urgently withdraws from. In the case of a pseudophobic person, what is most feared is the absence or loss of an attachment figure, or some other secure base, towards which he would normally retreat. Whereas in the case of phobia the clinician identifies the feared situation correctly, in the case of pseudophobia the true nature of the feared situation often goes unrecognized and the case is misdiagnosed as one of phobia. Although the label pseudophobia helps to draw attention both to the problem itself and to the tangled misconceptions about underlying psychopathology that abound in the literature, it is hardly suitable for regular use. Indeed, once the role that anxious attachment plays in these conditions is firmly grasped, it becomes clear that patients said to be suffering from free-floating anxiety, no less than those labelled here as pseudophobic, are in an acute or chronic state of anxiety about the availability of their attachment figure(s). In the chapter following we examine agoraphobia in the light of our discussion of school phobia. These terms apply when children not only refuse to attend school but express much anxiety when pressed to go. Their non-attendance is well known to their parents, and a majority of the children remain at home during school hours. Not infrequently the condition is accompanied by, or masked by, psychosomatic symptoms of one kind or another -for example, anorexia, nausea, abdominal pain, feeling faint. Fears of many kinds are expressed -of animals, of the dark, of being bullied, of mother coming to harm, of being deserted. Most come from intact families, have not experienced long or frequent separations from home, and have parents who express great concern about their child and his refusal to attend school. Relations between child and parents are close, sometimes to the point of suffocation. Truants from school do not express anxiety about attending, do not go home during school hours, and usually pretend to their parents that they are attending. Commonly they come from unstable or broken homes, and have experienced long and/or frequent separations or changes of mother figure. Relations between a truant and his parents are likely to be quarrelsome or distant. The validity of the distinction between school phobia and truancy is well attested, notably by the study of Hersov (1960a), who compares a series of fifty cases of school refusal with a matched series of fifty truants and with another contrast group, also drawn from a clinic population. Although several other studies are based on a series of cases seen in clinical practice, in none of them are results treated statistically. Instead, observations are presented descriptively and interwoven with a greater or less measure of theoretical interpretation. Among such studies, each based on a series of between twenty and thirty cases, are those by Talbot (1957), Coolidge and his colleagues (1957; 1962), Eisenberg (1958), and Davidson (1961). For her two papers Sperling (1961; 1967) draws on experiences with fifty-eight children, some of whom had long analytic treatment. Weiss reports the treatment and follow-up some years later of fourteen children and adolescents treated as inpatients (Weiss & Cain 1964; Weiss & Burke 1970). A number of empirically based articles on the family background of school refusers are published in the Smith College Studies in Social Work and reviewed by Malmquist (1965). A book by Clyne (200 1966), based on fifty-five cases seen in general practice, gives a vivid description of the many and varied clinical pictures encountered. Klein (1945), a book by Kahn & Nursten (1968), reviews by Frick (1964), Andrews (1966), and Berecz (1968), and several papers reporting on small numbers of cases that have been treated by one or another method, including some by behaviour therapy. At an empirical level there is substantial agreement among these many authors, both in regard to the personalities, behaviour, and symptoms presented by the children and in regard to the personalities, behaviour, and symptoms presented by the parents. Furthermore, there is widespread agreement that what a child fears is not what will happen at school, but leaving home. With the exception of Frick (1964), who expresses doubt, almost all students of the problem conclude that disagreeable features of school, for example a strict teacher or teasing or bullying from other children, are little more than rationalizations.

As infants become the following behaviors should be prohibited in all child care more mobile anxiety symptoms weight loss discount 5 mg buspar overnight delivery, the caregiver/teacher must create a safe settings and by all caregivers/teachers: space and impose limitations by encouraging activities that a) the use of corporal punishment anxiety symptoms child generic buspar 5mg otc. Brief verbal exprespunishment means punishment inficted directly on sions of disapproval help prepare infants and toddlers for the body including anxiety home remedies discount 5mg buspar overnight delivery, but not limited to: later use of reasoning anxiety disorder in children buy 5 mg buspar fast delivery. However anxiety symptoms for hiv purchase genuine buspar line, the caregiver/teacher 1) Hitting anxiety 12 year old boy 10mg buspar sale, spanking (refers to striking a child with an cannot expect infants and toddlers to be controlled by open hand on the buttocks or extremities with the verbal reprimands. School-age chil2) Demanding excessive physical exercise, excessive dren begin to develop a sense of personal responsibility and rest, or strenuous or bizarre postures; self-control and will recognize the removal of privileges (12). Children should not see hitb) Isolating a child in an adjacent room, hallway, closet, ting, ridicule, etc. Touch is especially important terrorizing, extended ignoring, isolating, or corrupting for infants and toddlers. Warm, responsive touches convey a child; regard and concern for children of any age. Adults should g) Any abuse or maltreatment of a child, either as be sensitive to ensuring that their touches (such as pats on an incident of discipline or otherwise. Child care c) That such child restraint techniques do not violate the forms, licensed/ registered provider. Corporal punishment by parents and f) That a designated and trained staff person, who associated child behaviors and experiences: A meta-analytic and should be on the premises whenever this specifc theoretical review. Spanking by parents and subsequent fcation needs to be done after a restraining incident occurs antisocial behavior of children. Arch Pediatric Adolescent Medicine in order to conform with the mental health code. Physical removal discipline: Child aggression and a maladaptive social information of a child is defned according the development of the child. American Academy of Pediatrics, Committee on Psychological her to a quiet place where s/he cannot hurt themselves or Aspects of Child and Family Health. Prevention of child abuse in early childhood giving a lot of attention to the behavior, distracting the child programs and the responsibilities of early childhood professionals and/or giving a time-out to the child. Staff director annually to discuss how their child is doing in the should be alert to repeated instances of restraint for indiprogram. Effective responses: Caregivers/teachers should informally share with parents/ Physical restraint. All In such a situation, children feel a continuity of affection and relevant legal documents, court orders, etc. Especially for infants and toddlers, attengivers/teachers should comply with court orders and written tion to consistency across settings will help minimize stress consent from the parent/guardian with legal authority, and that can result from notable differences in routines across not try to make the determination themselves regarding the caregivers/teachers and settings. Another ongoing source of stress for an infant or a young All aspects of child care programs should be designed child is the separation from those they love and depend to facilitate parent/guardian input and involvement. Of the various programmatic elements in the facility custodial parents should have access to the same develthat can help to alleviate that stress, by far the most imporopmental and behavioral information given to the custodial tant is the comfort in knowing that parents/guardians and parent/guardian, if they have joint legal custody, permission caregivers/teachers know the children and their needs and by court order, or written consent from the custodial parent/ wishes, are in close contact with each other, and can reguardian. Caregivers/teachers should also clarify with whom the child the encouragement and involvement of parents/guardspends signifcant time and with whom the child has primary ians in the social and cognitive leaps of the child provides relationships as they will be key informants for the caregivparents/guardians with the confdence vital to their sense of ers/teachers about the child and his/her needs. Communication should be munication between the administrator, caregiver/teacher sensitive to ethnic and cultural practices. The parent/guardand parent/guardian are essential to facilitate the involveian/caregiver/teacher partnership models positive adult ment and commitment of parents/guardians. Reweaving parents back into the fabric of English early childhood programs: Research in review. Sharing the care: What every provider and Medical Care or Threatening Incidents parent needs to know. Mother and father involvement in day care care for young children: Settings standards and resources. Parent/guardian support groups and parent/guardian e) To identify goals for the child; involvement at every level of facility planning and delivery f) To discuss resources that parents/guardians can are usually benefcial to the children, parents/guardians, access; and staff. Communication among parents/guardians whose g) To discuss the results of developmental screening. Compliance can be assessed by cord with the signature of the parent/guardian and the staff reviewing the records of these planned communications. Compliance can be of age and for children with special health care measured by interviewing parents/guardians and staff. Facilities should develop mechanisms for holding formal and informal meetings between staff and groups Caregivers/teachers should establish parent/guardian of parents/guardians. Fateachers should have a regularly established means of cilities should post the complaint and resolution procedure communicating to parents/guardians the existence of these where parents/guardians can easily see (or view) them. The ents/guardians is essential to promote their respective child caregiver/teacher should record parental/guardian participacare roles and to avoid confusion or conficts surrounding tion in these on-site activities in the facility record. In addition to routine meetings, special meetings can deal with crises and unique problems. Complaint and resoOne strategy for supporting parents/guardians is to facililution documentation records can help program directors tate communication among parents/guardians. The list should assist in developing resources, and recommend facility and include an annotation encouraging parents/guardians whose policy changes to the governing body. It is most helpful to children attend the same facility to communicate with one document the proceedings of these meetings to facilitate another about the service. The facility should update the list future communications and to ensure continuity of service at least annually. Facility-sponsored activities could take place outside facility hours and at other venues. Some parents/ Education Topics for Children guardians may resist providing this information. If so, the Health and safety education for children should include caregiver/teacher should invite them to view this exchange physical, oral, mental, emotional, nutritional, and social of information as an opportunity to express their own conhealth and should be integrated daily into the program of cerns about the facility (1). The specialist/professional safety, personal safety, what to do in an emergency, must also be certain that all communication shared with getting help and/or dialing 9-1-1 for emergencies); caregivers/teachers is shared directly with the parent/guardk) Confict management, violence prevention, and ian. These specialists may include, but are not limited to , bullying prevention; physicians, registered nurses, child care health consultants, l) Age-appropriate frst aid concepts; behavioral consultants. Activities should be accompanied by words of encouragement and praise for achievement. Children learn Facilities should encourage and support staff who wish to about health and safety by experiencing risk taking and breastfeed their own infants and those who engage in garrisk control, fostered by adults who are involved with them. Staff are consistently a model for children and ers should integrate education to promote healthy and safe should be cognizant of the environmental information and behaviors (1). Health and safety education does not have to print messages they bring into the indoor and outdoor learnbe seen as a structured curriculum, but as a daily compoing/play environment. The labels and print messages that nent of the planned program that is part of child developare present in the indoor and outdoor learning/play environment. Health and safety education supports and reinforces ment or family child care home should be in line with the a healthy and safe lifestyle (1,2). Opportunities for health promotion education in ing the types of foods that are available but by infuencing child care. The the program should strongly encourage all staff members Dietary Guidelines focus on increased healthy eating and to model healthy and safe behaviors and attitudes in their physical activity to reduce the current rate of overweight or contact with children in the indoor and outdoor learning/ obesity in American children (one in three in the nation) (6). Consultation can be sought from a child care health consultant or certifed health education specialist. Promising partnerships: How to develop learning possible indoors and outdoors should be supsuccessful partnerships in your community. Opportunities for health promotion education in topics and methods of presentation are widely available (8). Risk Watch: Cluster randomized controlled trial care by health professionals, nutrition education and physievaluating an injury prevention program. It can be ately discuss with the children anatomical facts related to helpful to place visual cues in the indoor and outdoor learngender identity and sex differences. Facilities Family Child Care Home should strive for developing common language and understanding among all the partners. Child Fam cal, oral, mental, emotional, nutritional, physical activity, and 17:7-8. In addition to the health and safety 83 Chapter 2: Program Activities Caring for Our Children: National Health and Safety Performance Standards topics for children in Standard 2. Opportunities for health promotion education in d) Managing emergency situations; child care. Child e) Monitoring developmental abilities, including care health consultation improves health and safety policies and indicators of potential delays; practices. Child care l) Physical activity and outdoor play and learning; health consultation: Evidence based effectiveness. For parents/guardians who may not have the opyear of staff continuing education in the areas of health, portunity to visit their child or observe during the day, there safety, child development, and abuse identifcation was the should be alternate forms of communication between the most signifcant predictor for compliance with state child staff and the parents/guardians. Child care staff often written journals that would go between facility and home, receive their health and safety education from a child care newsletters, electronic communication, or events.