Loading

Dulcolax

"Purchase genuine dulcolax, medicine identifier".

By: W. Zuben, M.A., M.D., Ph.D.

Deputy Director, University of Minnesota Medical School

The main potential sites of disease are the brain medicine and science in sports and exercise generic dulcolax 5mg mastercard, spinal cord treatment plantar fasciitis dulcolax 5 mg visa, cranial and peripheral nerves treatment 101 buy dulcolax 5 mg with visa, neuromuscular junction and muscles symptoms carbon monoxide poisoning purchase dulcolax without a prescription. If the amount of time is limited then it is better to spend time on the history and be selective about the examination concentrating it on the main areas of interest. Where relevant ask specifcally about a history of infections, seizures, head injuries, birth and childhood development, diabetes, hypertension and stroke. Enquire if there is a past history of neurological episodes similar to the presenting complaint and outline any investigations, their results and treatments received, and any persisting disabilities. Enquire if there is anyone else in the family with the same illness, if so record the full family tree with their names and ages and indicating any afected family members and any deaths and their causes if known. Personal & social history Ask concerning occupation, employment, travel, alcohol intake in number of units per week and smoking in pack years (packs per day times years smoked); if relevant ask concerning the use of recreational drugs. Enquire how the current illness has afected work and social life including time lost from work over the last 6 months. Have a neurological patient describe the home environment, caregivers, community and fnancial circumstances if relevant. Drugs, allergies List the medications the patient is taking including names, duration and dosages. William Howlett Neurology in Africa 15 Chapter 1 history and examination Chapter 1 history and examination Menses Record whether menses are normal and if the patient is pregnant or on the pill. Key points allow the patient time to tell the story of their ask if there is anything else you wish to tell me illness history determines the site of interest for listen to the patient neurological examination if patient is unable to give a history obtain it from family or friends General examination The neurological examination must be performed in the context of a general physical examination. This includes recording the vital signs and examination of the cardiovascular system including listening for carotid bruits, and the respiratory, abdominal, and musculoskeletal systems. This arises mainly because of technique and uncertainty over what is normal or abnormal. The best way to overcome this is to spend time early on learning the basic neurologic skills and then to practise on colleagues and patients until confdent. The main aim is to become familiar with the routine of neurological examination and range of normal fndings. The student will then gradually be introduced to abnormal fndings in patients with neurological disorders and to what are termed neurological signs. In general, neurological signs are objective, reproducible and cannot be altered by the patient whereas less reliable fndings tend to be variable, subjective and less reproducible. The neurological examination may involve an assessment of the level of consciousness, cognitive and mental function, cranial nerves, limbs and gait. Details concerning the clinical examination of level of consciousness and cognitive function are at the end of this chapter. In summary it is wise to listen attentively to the patients complaints, stick to the routine of a basic neurological examination and to concentrate the neurological exam on the problem area highlighted by the history. General observations Observe the patients general appearance, for any obvious neurological defcit and level of consciousness. The patients level of consciousness, alertness, higher cerebral function, mental state and ability to give a history become apparent during the history taking. Neurological disorders afecting speech, posture, movement and gait may also become apparent at this stage. In a routine neurological examination it is sufcient to ask the patient if there is any loss of smell (anosmia). This can be done by simply asking the patient to identify up to four familiar bedside items. Before the test the nasal airway 16 Part 1 Clinical skills Neurological Examination Cranial nerve examination should be shown to be clear by getting the patient to snif. Explain to the patient to close both eyes and block of one nostril by applying pressure with a fnger. In the manner shown in the diagram the item to be identifed is then presented to the other open nostril and the patient tries to identify the smell and its source. Patients may only become aware of the loss of smell whilst eating when the perception is often a loss of taste. The patient should stand 6 metres away from the chart and correct for any known refractive error by wearing appropriate glasses. Ask the patient to cover each eye in turn with his hand and fnd the smallest line that he can read fully without difculty. The numbers on the chart (below the line) correspond to the distance at which a person with normal vision should be able to see and identify the appropriate line. At the bedside setting crude levels of visual acuity can be established by using a small hand held chart. Colour vision is not tested routinely, however it can be tested by a using a book of Ishihara plates where at least 15/17 coloured plates identifed correctly is considered normal. The most common causes of decreased visual acuity are optical problems, mainly refractive errors in lens, followed by cataracts and lastly diseases involving the retina, macula and optic nerve. This means that testing for the pattern of visual feld loss is useful for localization of lesions along the visual pathway. Visual felds are always described and recorded from the perspective of the patient looking outwards with the felds divided into nasal and temporal halves. The main patterns of loss are homonymous & bitemporal hemianopia, & monocular blindness. Confrontation this involves sitting about 1 meter in front of the patient with your eyes at the same horizontal level. Hold your hands upright halfway between you and the patient held approximately half a meter apart and at about 30 cm above the horizontal. While looking at the patients eyes frst move the index fnger tip of one hand (or a 5-7 mm red pin head) and ask the patient to correctly identify which fnger moved. The patient should immediately point or indicate the hand on which the fnger moved. To examine the visual felds in each eye separately, ask the patient to cover one eye. Move your index fnger in each of the four quadrants starting in the temporal feld followed by the nasal feld in same manner as you did on confrontation for both eyes. Remember that the nose and prominent eyebrows may partially block vision and mistakenly give a feld defcit. Start behind the patients visual feld coming forward diagonally in a convex plane from all four quadrants at a 45 degree angle, northeast to southwest and northwest 18 Part 1 Clinical skills Neurological Examination Cranial nerve examination to southeast and the same in reverse asking the patient to indicate as soon as he sees the movement. The blind spot (optic nerve head) and any central feld defects can be easily identifed using red pin head moving in the horizontal plane from outside. Key points patients are often unaware of loss of visual peripheral visual felds are tested by perimetry felds examination major visual feld loss is identifed by main patterns of loss are homonymous confrontation & bitemporal hemianopia & monocular blindness Ocular fundi Ocular fundi are tested by fundoscopy. The aim of fundoscopy is to inspect the optic nerve head, arterioles, veins and retina. This is an important part of the neurological examination and is used mainly to exclude papilloedema or swelling of the optic nerve. Swelling of the optic disc may also be caused by infammation of the optic nerve and this is called papillitis. How to use an ophthalmoscope Students and young doctors at frst fnd fundoscopy difcult but the skill comes with training and practice. The most important thing to understand is the position of the optic nerve head within the feld of vision you are testing. The optic nerve head lays 15-20 degrees lateral to the point of fxation of the patients eyes and slightly below the horizontal and corresponds to the blind spot. Check the focus on the ophthalmoscope is set at zero and the light is bright, then sit opposite the patient and examine the right eye. With the ophthalmoscope in the right hand approach from the patients right side, look at the patients right eye from 30 cm away with the ophthalmoscope level or slightly below the patients eye about 15-20 degrees outside or lateral to the patients line of fxation or direction of gaze. Aim at the centre of the back of head and keep out of the line of sight of the other eye. You should be able to see the pupil as pink in colour; this is the normal retinal or red refex. Gradually move in towards the eye, encourage patient to continue to look or fxate at a point behind you straight ahead and bring ophthalmoscope to within 1-2 cm of the patients right eye. Its important to keep patients eye, point of fxation and ophthalmoscope all on the same plane. Adjust the lens for focus so that you can see the blood vessels clearly and follow blood vessels as they get larger and converge on the disc.

buy cheap dulcolax 5 mg on line

Occurrence of graft vasculopathy (11%) medicine lake generic dulcolax 5 mg without prescription, malignancy (11%) and freedom from severe renal dysfunction were identical in both groups 911 treatment discount 5 mg dulcolax otc. Further studies into observed differing responses in the development of donor specific isohemagglutinins and the implications for graft accommodation are warranted symptoms whiplash generic 5 mg dulcolax mastercard. Data included underlying conditions and demographics of the patients medicine images dulcolax 5 mg with mastercard, the isohemagglutinin titer before and after plasma exchange, and survival figures to date. All patients underwent a "3 times" plasma exchange before transplantation, requiring exchange volumes of up to 3209 mL. Isohemagglutinin titers that were as high as 1:32 preoperatively were reduced to a range of 01:16 posttransplantation. The authors determined that the studies generally had a high risk of bias and the results were inconclusive. Both share an array of neuropsychiatric symptoms and both may have a shared etiopathogenesis. Mean chorea severity for the entire group was significantly lower at the 1-month follow-up evaluation (overall 48% improvement). Although the between Apheresis Page 8 of 16 UnitedHealthcare Commercial Medical Policy Effective 11/01/2019 Proprietary Information of UnitedHealthcare. According to the authors, larger studies are required to confirm these clinical observations and to determine if these treatments are cost-effective for this disorder (Garvey, 2005). Rheumatoid Arthritis In a single institution observational study, Kitagaichi et al. An initial baseline assessment was performed prior to first treatment and then up to 4 additional assessments were performed at weeks 9, 16, 20, and 24. Ninety nine patients received 12 weekly procedures after being randomized to the active treatment arm or to the sham treatment arm (apheresis only). Evaluations were double-blinded and occurred at baseline and periodically for 24 weeks thereafter. Analysis of patients who completed all treatments and follow-up indicated that 15 of 36 (41. The authors concluded that immunoadsorption therapy was proven to be a new alternative in patients with severe, refractory disease. Participants received 3 months of blinded weekly lipoprotein apheresis or sham, followed by crossover. Secondary endpoints included measures of atheroma burden, exercise capacity, symptoms and quality of life. The researchers concluded that lipoprotein apheresis may represent an effective novel treatment for patients with refractory angina and raised lipoprotein(a). Study limitations included small study population and lack of appropriate blinding methods. The study may not have been sufficiently powered to detect differences between treatment and controls. Whether addition of extracorporeal therapies to renoprotective therapy can result in better renal recovery is still a matter of debate and there are currently no guidelines in this field (Fabbrini et al. A total of 63 patients received chemotherapy only and 84 patients were given both chemotherapy and plasmapheresis. No difference was observed in 6-month survival rate between plasmapheresis and control group (75% vs. The 6-month dialysis-dependent ratio was significantly lower in patients treated with both chemotherapy and plasmapheresis than chemotherapy alone (15. Severe Cryoglobulinemia In a 2018 review on the use of emergency apheresis in the management of plasma cell disorders, Kalayoglu-Besisik stated that in hepatitis C virus-related mixed cryoglobulinemias, plasmapheresis is indicated if rapidly evolving life threatening disease with immunosuppressive agent exists. In non-infectious mixed cryoglobulinemia plasmapheresis is indicated when the disease manifestations are severe, as a second line option. Rockx and Clark conducted a review of the medical literature over a 20-year span for evidence supporting or refuting the reported use of plasmapheresis for cryoglobulinemia. None had a clear report of the apheresis procedures or clearly defined quantitative outcomes. The quality and variability of the evidence precluded a meta analysis or systematic analysis however, the authors found that these studies weakly supported the use of plasma Apheresis Page 10 of 16 UnitedHealthcare Commercial Medical Policy Effective 11/01/2019 Proprietary Information of UnitedHealthcare. Further studies of greater rigor will provide better evidence to support or refute the use of plasma exchange in treating this condition (2010). Inflammatory Bowel Disease A large-scale, prospective, observational study was performed by Yokoyama et al. Concomitant medications, 5-aminosalicylic acids, corticosteroids, and thiopurines were administered to 94. However, this study did not translate research data into clinical guidelines that can be used to improve physician decision-making and patient care. Fourteen individuals made up the active treatment group, and 8 were in the placebo group. With this being the first trial of its kind in humans, further studies with larger participant groups are needed (2017). A 9-week tapering schedule of prednisone was pre-established in both study groups. The primary endpoint was steroid-free remission at week 24, with no re-introduction of corticosteroids. However, in life threatening cases with leukostasis that is not responsive to other modalities, leukapheresis can be considered with caution (2019). Apheresis Page 11 of 16 UnitedHealthcare Commercial Medical Policy Effective 11/01/2019 Proprietary Information of UnitedHealthcare. Multiple clinical trials studying therapeutic apheresis and inflammatory bowel disease have been completed but results have not yet been published. Addition of Granulocyte/Monocyte Apheresis to Oral Prednisone for Steroid dependent Ulcerative Colitis: A Randomized Multicentre Clinical Trial. Apheresis Page 12 of 16 UnitedHealthcare Commercial Medical Policy Effective 11/01/2019 Proprietary Information of UnitedHealthcare. Light chains removal by extracorporeal techniques in acute kidney injury due to multiple myeloma: a position statement of the Onconephrology Work Group of the Italian Society of Nephrology. Immunoadsorption for the treatment of rheumatoid arthritis: final results of a randomized trial. Exchange blood transfusion compared with simple transfusion for first overt stroke is associated with a lower risk of subsequent stroke: a retrospective cohort study of 137 children with sickle cell anemia. Apheresis as novel treatment for refractory angina with raised lipoprotein(a): a randomized controlled cross-over trial. Safety and efficacy of the leukocytapheresis procedure in eighty-five patients with rheumatoid arthritis. Current approach to diagnosis and management of acute renal failure in myeloma patients. Using donor exchange paradigms with desensitization to enhance transplant rates among highly sensitized patients. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: the Eighth Special Issue. Role of Plasmapheresis in the Management of Acute Kidney Injury in Patients With Multiple Myeloma: Should We Abandon It Apheresis Page 13 of 16 UnitedHealthcare Commercial Medical Policy Effective 11/01/2019 Proprietary Information of UnitedHealthcare. Effects of Prosorba column apheresis in patients with chronic refractory rheumatoid arthritis. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: the Seventh Special Issue. Therapeutics and Technology Assessment Subcommittee of American Academy of Neurology. Evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. Exchange versus simple transfusion for acute chest syndrome in sickle cell anemia adults. Erythrocytapheresis in children with sickle cell disease and acute chest syndrome. Lower alloimmunization rates in pediatric sickle cell patients on chronic erythrocytapheresis compared to chronic simple transfusions.

Buy cheap dulcolax 5 mg on line. Natalia Dyer's shocking appearance change.

buy dulcolax 5 mg with amex

This document is shared subject to 92507 treatment code buy dulcolax 5 mg without prescription the express understanding that it must be reviewed by legal counsel and adapted as appropriate in other cases symptoms quiz cheap dulcolax 5mg on-line. This document is intended for informational purposes only medications you can take when pregnant order 5mg dulcolax, and does not constitute legal advice medicine 4h2 pill purchase online dulcolax. I designate my (relationship), (name), as my alternate Agent to handle the control and management of my education on my behalf if my Agent is ever unable or unwilling to serve. An alternate Agent shall have the same powers under this instrument as the initial Agent. By the granting of this Special Durable Power of Attorney for Matters Concerning Education, I intend to give my Agent the broadest possible powers to represent my interests in all aspects of any dealings or decisions involving my education. To provide opportunities for me to engage in any public and / or private educational programs. To provide opportunities for me to engage in any recreational activities having an educational purpose. To investigate and arrange for opportunities for me to engage in educational activities that provide occupational training. To negotiate and approve on my behalf reasonable accommodations in education services as required under Section 504 of the Rehabilitation Act of 1973. To attend and participate in all school meetings and conferences pertaining to me. I hereby release all such persons, organizations, corporations or other entities from any liability arising from their reliance on this instrument. I have advised my client concerning his or her rights in connection with this Special Durable Power of Attorney for Matters Concerning Education. Students are not obligated to disclose any part of this information to their instructors. Instructors should gently touch the student on the shoulder, without discussion, when the student displays continuous hand and arm flapping; if necessary, the student will exit the classroom to calm down. Anxieties related to new relationships and communications may result in the student displaying stuttering and repetitive speech. The student repeats information to confirm understanding of new information and details. The student will raise their hand and write down questions during class to be asked when directed by instructor, a gentle reminder is sufficient should the student ask questions without being called upon. Many display eccentric / odd behavior, difficulty interacting with peers, difficulty with changes and transitions, and poorly developed skills in perceiving nonverbal cues. Since the age of six, I have been diagnosed with Aspergers Syndrome, also known as highly functional autism. It is very easy to misinterpret this condition with the normal teenager characteristics of being quiet, not very assertive and not willing to volunteer information about feelings or problems, etc. It is very easy to mistake the trials and tribulations of being a teenager, or young adult with characteristics a person has with Aspergers. My disability related issues are that I have difficulty processing information and instructions and lack organizational skills. I also have difficulty multitasking, understanding directions and staying on task. As you get to know me better, you will find out that I can relate to any subject matter that I am studying at the time to trains, tornadoes or spiders. I am continually improving and have made great strides in becoming a responsible young adult; however, I need the assistance of my family and instructors to help reinforce this. For these reasons, I am offering a few suggestions for you to consider that may help me to stay focused. Use visual cues whenever possible, visual cues work better than verbal cues for individuals with Aspergers. I intend to utilize the Academic Service Center, however, I may need to schedule a time with you to receive help in one of the labs offering assistance in math or writing. I have a tendency to become very anxious and nervous which interferes with my ability to concentrate and process the material before me. I have made terrific progress developing my social skills and behavior the past few years. I am gaining self-confidence and feel comfortable participating in class discussions. I understand that I may have a few more obstacles and challenges in life than others; however, I am confident that with the help and support of my family and instructors, I can overcome these obstacles and challenges and be successful in school and in life. Use teacher selected groups Many have difficulties with social interactions and will not join a group unless assigned. Students with Aspergers have to stop thinking current thoughts, decipher the question, formulate the answer, and then respond. Repeat instructions Help decipher social situations such as body language, facial expressions, etc. Visual If students are sensitive to light, seat the students where they are not in direct sunlight. The maximum number of times you can respond, if you know the answer, is three for each class. If you have questions, but your questions are not directly related to the class discussion or the lecture, please wait. If you speak in a loud voice, some people may be afraid to continue a conversation with you, especially people who dont know you very well. Carol Gray of the Gray Center for Social Learning and Under standing, created Social Stories. The stories are sometimes written in the first person for the student using it because it is more effective. A "meltdown" is when I get completely out of control and do things like hit myself and fall on the floor. If my stress symptoms get worse instead of better, I need to quietly leave the classroom before I have a "meltdown. When I successfully prevent a "meltdown," I will be proud, and class will go smoothly. Teachers use essay questions to determine if students understand complex ideas, especially in subjects like history and literature. Essay questions can be difficult and frustrating for autistic people because you have to think a lot, use many words to answer them, and there is never just one right answer. Even students who are not autistic think essay questions are the hardest kind to answer and the hardest to get right. To get a good grade on an essay question, it helps a lot if you have some idea of what the teacher thinks is important for you to know about the subject of the question. To get the maximum points on an essay question, you have to study class material enough so you understand the concepts and ideas of the subject. Knowing basic facts like dates, terms, and names helps you to answer essay questions, but is usually not enough to get the best grade. It will help me if I know how often and when each of my teachers will be giving essay questions. It will help me if I ask the teacher to explain what they usually are looking for in essay questions. It will also help me if I can see samples of questions each teacher has used in the past and what the teacher considers good answers to those questions. If you know the subject pretty well, you can usually come up with an answer that gets some points even if you dont know everything. Essay questions help you prepare for life after college by practicing writing skills. An essay question helps you practice that job skill by explaining what you know to the teacher. Learning to figure out what a teacher wants you to discuss in an essay question is good practice for autistic people who have trouble understanding how others think. Set up a time to visit each of my teachers at their office and talk about their questions. Ask each teacher to show me samples of their essay questions, and discuss what correct answers look like. Ask each teacher what parts of the material they think are most important to know. Plan my time so I can study all the material, even if that interferes with my hobbies. It refers to a group of five disorders characterized by delays in the development of multiple basic functions, including communication and socialization.

order cheap dulcolax on-line

Childhood Disintegrative Disorder Childhood Disintegrative Disorder is characterized by regression in multiple areas symptoms zika virus buy 5mg dulcolax overnight delivery. Individuals with Childhood Disintegrative Disorder also have significant communication deficits medicine allergic reaction discount 5mg dulcolax mastercard, social interaction impairments treatment regimen order dulcolax online pills, and restricted medicine woman dr quinn purchase 5 mg dulcolax free shipping, repetitive and stereotyped behaviours and interests. This disorder is also referred to as Hellers Syndrome and is much less common than Autistic Disorder. Myth #1: All individuals with autism spectrum disorders avoid eye contact and social contact. People with autism spectrum disorders are a diverse group, so it is difficult to use words such as all or every when describing those with the syndrome. Although social difficulties are a hallmark of the disorder, many individuals with autism spectrum disorders display some level of social interest and make some attempt to initiate social interactions on a frequent basis. Many individuals with autism spectrum disorders display affection and demonstrate a preference for social activities over solitary pursuits. Myth #2: People with autism spectrum disorders possess extraordinary skills or talents. The vast majority of people diagnosed with autism spectrum disorders do not possess genius abilities like the character depicted in the popular movie Rainman. However, most individuals with autism spectrum disorders display uneven or scattered skill development. Although questions remain about the causes of autism spectrum disorders, it has been empirically demonstrated that parents of children diagnosed with autism spectrum disorders do not differ from parents of typical children. It is now generally accepted that autism spectrum disorders is neurological in origin and that children are born with the syndrome. These fall into four major categories: communication characteristics social interaction characteristics unusual/challenging behaviour characteristics learning characteristics. Other characteristics of individuals with autism spectrum disorders include: unusual patterns of attention unusual responses to sensory stimuli anxiety. Communication All people with autism spectrum disorders experience language and communication difficulties, although there are considerable differences in language ability among individuals. Some individuals are nonverbal while others have extensive language with deficits in the social use of language. People with autism spectrum disorders may seem caught up in a private world in which communication is unimportant. Students with autism spectrum disorders often have difficulty comprehending verbal information, following long verbal instructions and remembering a sequence of instructions. The extent of difficulty varies among individuals, but even those who have normal intelligence, usually referred to as high-functioning, may have difficulty comprehending verbal information. Implications for instruction Programs for students with autism spectrum disorders and other Pervasive Developmental Disorders include comprehensive communication assessment and intervention. This involves assessment by a speech-language pathologist as well as informal observation and classroom-based evaluation. Assessment serves as the basis for identifying goals and strategies for facilitating 10/ Teaching Students with Autism Spectrum Disorders 2003 Alberta Learning, Alberta, Canada development of receptive and expressive language skills, particularly pragmatic skills. Instruction should emphasize: paying attention For more on strategies to facilitate the development of imitating communication skills, see comprehension of common words and instructions pages 6068. Communication goals should emphasize the functional use of language and communication in various settings. Social Interaction Students with autism spectrum disorders demonstrate qualitative One must separate the differences in social interaction, and often have difficulty variables of social interaction establishing and maintaining relationships. These People with autism desire emotional contact with other difficulties are not a lack of interest or unwillingness to interact people but they are stymied by with others but rather an inability to distill social information from complex social interaction. Understanding social situations requires language processing and nonverbal communication, which are often areas of deficit for people with autism spectrum disorders. They tend to have difficulty using nonverbal behaviours and gestures in social interaction. Students with autism spectrum disorders often are not able to understand the perspectives of others, or even understand that other people have perspectives that could be different from their 11 own. They may also have difficulty understanding their own, and other peoples, beliefs, desires, intentions, knowledge and perceptions. They may have problems understanding the connection between mental states and actions. For example, children with autism spectrum disorders may not be able to understand that another child is sad, even if that child is crying, because they are not themselves sad at that particular moment. Characteristics Associated with Autism Spectrum Disorders /11 Alberta Learning, Alberta, Canada 2003 Students with autism spectrum disorders have a tendency to play with toys and objects in unusual and stereotypical ways. Some children with autism spectrum disorders play near others but do not share and take turns, while others may withdraw entirely from social situations. Social interaction can be classified into three 12 subtypes along this continuum: aloofthose who show no observable interest or concern in interacting with other people except for when necessary to satisfy basic personal needs; they may become agitated when in close proximity to others and may reject unsolicited physical or social contact passivethose who do not initiate social approaches but will accept initiations from others activethose who will approach for social interaction but do so in an unusual and often inappropriate fashion. Students with autism spectrum disorders may demonstrate social behaviour that fits into more than one subtype. Implications for instruction Social skill development is essential for students with autism spectrum disorders and it is a critical component in developing plans for managing challenging behaviours. Many children with autism spectrum disorders develop social interest but do not For more on strategies to facilitate the development of possess the social skills necessary to successfully initiate or social interaction skills, see maintain interactions. It is generally necessary to target specific skills for explicit instruction and provide support to encourage students to consistently use them. The following social skills are generally considered to be critical to social success and should be explicitly taught: tolerating others in ones work and play space imitating the actions and vocalizations of others engaging in parallel activities with others sharing materials taking turns within the context of a familiar activity using eye contact to initiate and maintain interactions. In addition, many students with autism spectrum disorders have challenging behaviours, such as aggression, destruction, screaming, self-injurious behaviours and/or tantrums. Given that most individuals with autism spectrum disorders are not able to effectively communicate their thoughts and desires, it is not surprising that they rely on their behaviour to communicate specific messages. For instance, a student may use aggression or destruction to communicate that a task is too difficult. Alternatively, some students may use these behaviours to avoid activities or manage their anxiety. Teachers need to look below the surface to identify the message a student is trying to communicate. Implications for instruction Many of the odd, stereotypical behaviours associated with autism spectrum disorders may be caused by other factors, such as hypersensitivity or hyposensitivity to sensory stimulation, difficulties understanding social situations, difficulties with changes in routine and anxiety. The instructional plan needs to incorporate strategies for: expanding students interests developing skills across a variety of functional areas helping students monitor their level of arousal or anxiety preparing students for planned changes facilitating ways to calm down and reduce anxiety. In planning instruction, teachers need to consider the problematic behaviour and its function for that particular student. Rather than attempting to control or eliminate all changing behaviours, successful teaching strategies often focus on making Characteristics Associated with Autism Spectrum Disorders /13 Alberta Learning, Alberta, Canada 2003 environmental adaptations to decrease inappropriate behaviours, and/or helping students learn more appropriate behaviours that will serve the same function (a functional approach to challenging behaviour is discussed in detail in Chapter 6). Learning Students with autism spectrum disorders have psycho-educational profiles that are characterized by uneven patterns of development. Studies indicate that there may be deficits in many cognitive functions, yet not all are affected. In addition, there may be deficits in complex abilities, yet simpler abilities in the same area 13 may be intact. Current research has identified some of the cognitive features commonly associated with autism spectrum disorders, including: deficits in paying attention to relevant cues and information, and attending to multiple cues receptive and expressive language impairments, particularly the use of language to express abstract concepts deficits in concept formation and abstract reasoning impairment in social cognition, including deficits in the capacity to share attention and emotion with others, and understand the feelings of others inability to plan, organize and solve problems. Some students have stronger abilities in the areas of rote memory and visual-spatial tasks than they have in other areas. They may actually excel at visual-spatial tasks, such as putting puzzles together, and perform well at spatial, perceptual and matching tasks. Some may be able to recall simple information but have difficulty recalling more complex information. Yet some higher-functioning individuals are relatively capable of identifying words, applying phonetic skills and knowing word meanings. Similarly, a student who is high-functioning may perform numerical computations relatively easily but be unable to solve mathematical problems. Implications for instruction these cognitive variations result in patterns of strengths and weaknesses in a students academic performance, social interaction and behaviour. Education programs should be based on the unique combination of strengths and needs of individual students. Programs may need to be modified on an ongoing basis to ensure they are appropriate. Many students with autism spectrum disorders have deficits in attention and language development, problems with concept For more on visual strategies, formation and difficulties with memory for complex information.