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F: Enlarged version of E [red dashed box]: the subfoveal deposits (*) are amorphous acne zinc purchase accutane without a prescription. Moderate reflectivity from vitelliform deposits is visible below the detached retina skin care giant crossword buy cheap accutane online. F: Enlarged version of E [red dashed box]: the vitelliform deposits are clearly visible (*) acne 415 generic accutane 5mg with amex. In addition acne removal tool purchase accutane 30 mg amex, the photoreceptor outer segment has merged with the vitelliform deposits and cannot be distin guished. The structure of the outer retinal layers is well preserved in the area without retinal detachment (blue dashed circle). Subfoveal vitelliform deposits get smaller and eventually disappear leaving behind a foveal detachment. The deposits disappear with time followed by 254 Chapter 7 Retinal degeneration 7. Lesions occur in the skin, gastrointestinal tract, cardio 2) Le Saux O, Urban Z, Tschuch C, et al. Outer retinal tubulation: a novel the peripapillary region that are caused by tears in Bruchs mem optical coherence tomography finding. E: Enlarged version of D [red dashed box]: the undulation of Bruchs membrane (7) and the disruption in Bruchs membrane (red dashed circle) are clearly visible. The granular, highly reflective dots inside the neural retina are either lipid deposits or macrophages that have phagocytized erythrocytes and deposited lipids. F: Enlarged version of E [red dashed box]: Mild reflective lesions are seen within the polypoidal lesion . The outer retinal tubulation is often exhibiting a small highly reflective dot in its center. Image interpretation points the biological explanation of outer retinal tubulation is un those seen in retinoblastoma. Slowly progressive cancer-associated Small cell lung cancer is well known as an underlying disease, and retinopathy. Symptoms are progressive and often follow a relatively acute or subacute course, although cases with gradual progression are also encountered. As mentioned above, a negative anti-recoverin anti body test cannot rule out this disease; in these cases, more spe cific laboratory tests are required to determine the presence or absence of autoantibodies for other retinal antigens. The sample size is insufficient to examine the differences with retinitis pigmentosa. Choroidal background fluorescence is mottled and has a salt-and-pepper appearance. It is unclear whether this is an inherent pattern for this condition or whether these are secondary changes. Image interpretation points In this case, the patient had significant bilateral concentric on the degeneration of the outer retinal layers evident on visual field contraction. The area of hyperfluorescence corresponds to the hyperfluorescent area on fundus autofluorescence. Ueber familiares Vorkommen von Retinitis punctata albescence Bietti crystalline dystrophy is a hereditary retinal degenerative (Verbunden mitDystrophia marginalis cristallinea cornea). Clinical biochemical and it can be confused with typical retinitis pigmentosa, this disease pathologic correlations in Biettis crystalline dystrophy. Choroidal imaging in inherited retinal (2) disease using the technique of enhanced depth imaging optical coher Japanese and Chinese people. These structures are thought to be outer retinal layer structures(7) reported as outer retinal tubu lations. In our cases, outer retinal tubulation was seen in all cases of crystalline dystrophy. B: Enlarged version of A [white dashed box]: Small yellowish-white deposits are visible . There is an area of almost normal autofluorescence that corresponds to the foveal area of relatively normal retinal color in the fundus photograph. Around the area of extensive hypo flurescence, there is an mixed appearance of hypofluorescence and normal fluorescence exhibiting in a granular mottled appearance. Three round or ovoid structures are seen in a line inferonasal to the fovea centralis . Round or ovoid structures (outer retinal tubulation) can be seen in the outer nuclear layer (blue dashed circles). Image interpretation points There is no significant difference between the degeneration gated. The basic pathogenesis of these structures is tion, however, is more commonly found in Bietti crystalline unknown, but they can be seen in various degenerative diseases dystrophy. There is no optic disc atrophy and narrowing of the retinal artery is insignificant. Cross-sections of outer retinal tubulation are lined up consecutively in the area indicated by the blue dashed circle. Image interpretation points When examined closely, small, a highly reflective punctiform tion. While it is unclear what these represent, they may be simi structures can be seen in the center of the outer retinal tubula lar to retinal rosette formations. In contrast in cone dystrophy, the retinal struc ture of the intermediate periphery is often well preserved since Background degeneration starts near the fovea centralis. Frequent symptoms include night blind receptor outer segment occurs first, followed by thinning of the ness, dark adaptation impairment and photophobia. There is continued gresses, tunnel vision typically advances from the intermediate loss of the photoreceptor outer segment, finally resulting in fur periphery to the periphery, eventually leading to loss of central ther thinning of the outer nuclear layer and outer plexiform layer. However, as mentioned above, there are few cases in strongly correlated with visual function. Thickness of receptor and post-receptor retinal layers in patients with retinitis pigmentosa measured with fre quency-domain optical coherence tomography. Optical coherence tomography of cys toid macular edema associated with retinitis pigmentosa. The prevalence of cystoid macular oedema in retinitis pigmentosa patients determined by optical coher 7 ence tomography. Visual acuity is related to parafoveal retinal thickness in patients with retinitis pigmentosa and macular cysts. Photoreceptor integrity and visual acu ity in cystoid macular oedema associated with retinitis pigmentosa. Optical coherence tomography findings in patients with retinitis pigmentosa and low visual acuity. The transition zone between healthy and diseased retina in patients with retinitis pigmentosa. The association between visual acuity and central retinal thickness in retinitis pigmentosa. Retinal laminar architecture in human retinitis pigmentosa caused by Rhodopsin gene mutations. Correlation between visual function and photoreceptor inner/outer segment junction in patients with retinitis pigmentosa. Optical coherence tomographic pat tern and focal electroretinogram in patients with retinitis pigmentosa. Association between abnormal au tofluorescence and photoreceptor disorganization in retinitis pigmento sa. Multiple, relatively large, patchy hypofluorescent foci are visible peripheral to the vascular arcade. Choroidal background fluorescence appears almost normal where the retinal color is also normal. F: Enlarged version of E [red dashed box]: Small cystoid spaces are visible near the fovea. The outer retinal layer structure is relatively well preserved in the area indicated by . Mild hyperfluorescence surrounds this region which is itself surrounded by another region of hypofluorescence forming a ring-shape. In addition, only a small part of the outer nuclear layer appears to be remaining. The outer retinal layer structure has completely disappeared even further peripherally. The color of the macula is relatively normal, but the the area peripheral to the vascular arcades is degenerative and exhibiting a grey appearance.

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The following material on the use of both the ophthalmo scope and otoscope has been prepared by Drs skincare for 40 year old woman buy accutane 5mg with mastercard. The facilities of the Biomedical Communications Center at the New York State Veterinary College were used and we are indebted to skin care tips discount 40mg accutane the State University of New York for their generosity skin care yoga purchase genuine accutane line. In order to acne quitting smoking accutane 40mg on line adequately perform ophthalmoscopy, a semi-darkened area should be obtained. Dilatation of the pupil can be accomplished with to 1 per cent Tropicamide drops utilizing one drop in each eye, waiting 10 minutes and administering the drops again. In order to visualize the right eye with the direct ophthalmoscope, the ophthalmoscope should be held in the right hand, the right eye used and one should stand to the right side of the animal to be examined. When examining the left eye, the left hand holds the ophthalmoscope, the left eye is used and the examiner stands to the left of the animal. The index fnger of the hand holding the ophthalmoscope is placed on the lens dial in order to change lenses when necessary. In using the direct ophthalmoscope, place the lens dial at 0 setting and hold the ophthalmoscope at 20 inches from the patients eye. Once the tapetal refex is obtained, bring the ophthalmoscope to within one inch of the patients eye and place the setting on (1) to (3) to view the optic disc and retina. Inserting more plus lenses into the ophthalmoscope focuses the lens on the more anterior structures within the eye. In examining the left eye the direct ophthalmoscope is held in the left hand and the right hand is used to prevent the head from hitting the ophthalmoscope. Indirect ophthalmoscopy offers several very distinct advantages over direct ophthalmoscopy: (1) the indirect image has less magnifcation and allows for less distortion and a much larger feld of view of the fundus than direct ophthalmoscopy; (2) indirect ophthalmoscopy permits examination at a safe distance from fractious animals; and (3) when the binocular indirect ophthalmoscope is used, a stereoscopic view of the fundus can be obtained. The use of a focal source of illumination and a good aspheric viewing lens permits the observer to perform monocular indirect ophthalmoscopy. Monocular indirect ophthalmoscopy requires that the animals head be restrained by an assistant while examination is being performed. The convex aspheric viewing lens is held in the right hand and interposed between the eye and the focal source of illumination. The lens is held in front of the eye so that the refected rays of light are brought into focus at the principal focus of the condensing lens, creating a real inverted image. The degree of magnifcation of the fundus depends on the dioptric power of the lens. A 20 diopter lens providing approximately 3 x magnifcation is excellent to learn with. The lower the dioptric power of the lens, the more inherent the magnifcation and the more diffcult the lens becomes to use. When using the indirect lens, the light beam and condensing lens must be kept in the same plane, and the lens and light source kept at the same distance from the animals eye. The Finoff transilluminator is held at eye level with the left hand and a 20 diopter aspheric viewing lens is held in the right hand. The light beam may be used as a method of illuminating the cornea and iris, for detecting foreign bodies in the cornea, and irregularities of the pupil. Lens opaci ties can easily be detected by looking at the pupil through the peep hole O at a distance of about 6 inches (15 cm. The normal fundus of the dog is characterized by the usual presence of three major venules with the direction being superiorly, inferonasally and inferotemporally. There are approximately 20 arterioles emanating from the disc in a radial pattern. The tapetum develops its natural color, usually a shade of pastel, after the dog is four months of age. Absence of the tapetum and lack of pigment in the retinal pigment cell layer and choroid gives the fundus a red refex and the tigroid appearance of the choroidal circulation can be visualized. Lack of tapetum in the dog is not unusual, especially in certain breeds such as the Weimeraner, Dalmatian, and Chihuahua. In the normal fundus of the cat, the optic disc is small and a peripapi/lary pigment ring is frequently present. There are three major arterioles leaving the disc; one superiorly, one inferonasally and one more infero temporally. The horse has a large number of small blood vessels that extend radially for a short distance from the optic disc. The optic disc is always located in the non-tapetal zone, temporally and slightly below the junctional area. The optic disc in the horse is slightly cupped centrally and usually salmon pink in color. Scattered in an even pattern of distribution through the tapetal area are pigmented dots, (The Stars of Winslow). The fundus of the ox and sheep are quite similar, having three or four major venules accompanied by parallel running arterioles. Hyaloid remnants attached to the optic nerve are commonly seen in sheep, cattle and goats. In the normal fundus of the Rhesus monkey, the optic disc is usually elliptic to ovoid with the long axis being vertical. Blood vessels in the primate fundus enter and leave from the central portion of the disc and there is a central artery and vein. The fundus background is usually a shade of brown and occasional choroidal circulation can be seen. A coloboma of the optic nerve is a congenital defect characterized by a fssure or hole in the optic nerve usually at the 6 oclock position (typical coloboma). Colobomas are seen most frequently in the collie breed as part of the collie ectasia syndrome. Retinal detachment in the dog, characterized by a grayish-white sheet of retinal tissue detached from the pars ciliaris retinae and remaining attached to the optic nerve. Retinal detachments can be classifed on the basis of etiology into 3 different types: (1) exudative detachments; (2) traction detachments; and (3) rhegmatogenous detachments. The rhegmatogenous detachments are associated with retinal holes and are not commonly found in animals. Most types of retinal detachments seen in animals are giant dialyses in which large areas of the retina have become detached. Advanced progressive retinal atrophy in the dog: progressive retinal atrophy has been observed in more than 30 breeds of dogs. Progressive retinal atrophy can be subdivided into generalized progressive retinal atrophy and central progressive retinal atrophy. Central progressive retinal atrophy is a retinal pigment cell dystrophy found in the Golden Retriever, Labrador, Shefty and other breeds. The disease is characterized by loss of central vision that progresses to total visual loss. Generalized retinal atrophy in the cat: advanced retinal degeneration in the cat is usually clinically noticed late in the stage of disease once severe visual diffculty is present. The retinal degeneration affects both eyes and is characterized by widely dilated pupilf, avascularity of the retina and a greatly increased tapetal refectivity. In the cat, central progressive retinal atrophy that can advance to total retinal degeneration has been associated with a diet defcient in Taurine, an amino acid. The auricular cartilage attaches to the external acoustic meatus where the cartilage is rolled into a tube. The horizontal ear canal is formed by the auricular cartilage laterally and the annualar cartilage medially. The tympanic membrane separates the horizontal external ear canal from the middle ear. A discussion of the middle and inner ear is not appropriate here, but may be found in the following reference: De Lahunta Alexander; Veterinary Neuroanatomy and Clinical Neurology. Infammation of the external ear canal (otitis externa) is a very common disease problem in the dog and cat. In dogs, the problem is more often associated in those dogs with hair growing in the ear canals and in dogs with pendulous ears. Poodles, Cocker Spaniels and Basset Hounds are particularly prone to developing otitis externa. Welch Allyn otoscopes are available in two types: a closed head and an operating otoscope with an open head, rotatable magnifying lens and speculum holder.

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As we shall see later acne yogurt buy cheap accutane 40 mg line, cone-connected circuits of neurons are less convergent in that fewer cones impinge on second order neurons acne 25 cheap 30 mg accutane, than rods do in rod-connected pathways acne location meaning order accutane 40 mg with visa. This is again due to acne antibiotic treatment purchase accutane 5mg mastercard the greater numbers and increased packing-density of ganglion cells needed for the cone pathways in the cone dominant foveal retina as compared the rod-dominant peripheral retina. Vertical view of Golgi stained Muller glial cells (59 K jpeg image) Throughout the retina the major blood vessels of the retinal vasculature supply the capillaries that run into the neural tissue. Capillaries are found running through all parts of the retina from the nerve fibre layer to the outer plexiform layer and even occasionally as high as in the outer nuclear layer. Nutrients from the vasculature of the choriocapillaris (cc) behind the pigment epithelium layer supply the delicate photoreceptor layer. The center of the fovea is known as the foveal pit (Polyak, 1941) and is a highly specialized region of the retina different again from central and peripheral retina we have considered so far. Radial sections of this small circular region of retina measuring less than a quarter of a millimeter (200 microns) across is shown below for human (Fig. Vertical section of the human fovea from Yamada Johnson (1991) (1969) (59 K jpeg image) (78 K jpeg image) the foveal pit is an area where cone photoreceptors are concentrated at maximum density with exclusion of the rods, and arranged at their most efficient packing density which is in a hexagonal mosaic. This is more clearly seen in a tangential section through the foveal cone inner segments. Tangential section through the human fovea (59 K jpeg image) Below this central 200 micron diameter central foveal pit, the other layers of the retina are displaced concentrically leaving only the thinnest sheet of retina consisting of the cone cells and some of their cell bodies. Radially distorted but complete layering of the retina then appears gradually along the foveal slope (right and left sides of the figure) until the rim of the fovea is made up of the displaced second and third order neurons related to the central cones. Here the ganglion cells are piled into six layers so making this area, called the foveal rim or parafovea (Polyak, 1941), the thickest portion of the entire retina. The whole foveal area including foveal pit, foveal slope, parafovea and perifovea is considered the macula of the human eye. Familiar to ophthalmologists is a yellow pigmentation to the macular area known as the macula lutea. This pigmentation is the reflection from yellow screening pigments, the xanthophyll carotenoids zeaxanthin and lutein (Balashov and Bernstein, 1998), present in the cone axons of the Henle fibre layer. The macula lutea is thought to act as a short wavelength filter, additional to that provided by the lens (Rodieck, 1973). As the fovea is the most essential part of the retina for human vision, protective mechanisms for avoiding bright light and especially ultraviolet irradiation damage are essential. Ophthalmoscopic appearance of the retina to show macula lutea (39 K jpeg image) Fig. Vertical section through the monkey fovea to show the distribution of the macula lutea. The dark pattern in the foveal pit extending out to the edge of the foveal slope is caused by the macular pigment distribution (Snodderly et al. Appearance of the cone mosaic in the fovea with and without macula lutea (59 K jpeg image) If one were to visualize the foveal photoreceptor mosaic as though the visual pigments in the individual cones were not bleached, one would see the picture shown in Figure 16 (lower frame) (picture from Lall and Cone, 1996). The short-wavelength sensitive cones on the foveal slope look pale yellow green, the middle wavelength cones, pink and the long wavelength sensitive cones, purple. If we now add the effect of the yellow screening pigment of the macula lutea we see the appearance of the cone mosaic in Figure 16 (upper frame). An effect akin to the mosaic "wearing sunglasses": the protective value of the xanthophyll screening pigment can be appreciated (picture from Lall and Cone, 1996). There are two sources of blood supply to the mammalian retina: the central retinal artery and the choroidal blood vessels. Fundus photograph showing flourescein imaging of the major arteries and veins in a normal human right eye retina. The vessels emerge from the optic nerve head and run in a radial fashion curving towards and around the fovea (asterisk in photograph) (39 K jpeg image) (Image courtesy of Isabel Pinilla, Spain) the arterial intraretinal branches then supply three layers of capillary networks i. The precapillary venules drain into venules and through the corresponding venous system to the central retinal vein (Fig. The outer capillary network runs from the inner plexiform layer to the outer plexiform layer thought the inner nuclear layer (Zhang, 1974). As will be noticed from the flourescein angiography of Figure 17, there as a ring of blood vessels in the macular area around a blood vessel and capillary-free zone 450-600 m in diameter, denoting the fovea. The macular vessels arise from branches of the superior temporal and inferotemporal arteries. At the border of the avascular zone the capillaries become two layered and finally join as a single layered ring. The collecting venules are more deep (posterior) to the arterioles and drain blood flow back into the main veins (Fig. The macular vessels of the monkey eye form a ring around monkey derived from more than 80 microscope fields. Each of the posterior ciliary arteries break up into fan shaped lobules of capillaries that supply localized regions of the choroid (Hayreh, 1975). The macular area of the choroidal vessels are not specialized like the retinal blood supply is (Zhang, 1994). The arteries pierce the sclera around the optic nerve and fan out to form the three vascular layers in the choroid: outer (most scleral), medial and inner (nearest Bruchs membrane of the pigment epithelium) layers of blood vessels. This is clearly shown in the corrosion cast of a cut face of the human choroid in Figure 21a (Zhang, 1974). The corresponding venous lobules drain into the venules and veins that run anterior towards the equator of the eyeball to enter the vortex veins (Fig. The vortex veins penetrate the sclera and merge into the ophthalmic vein as shown in the corrosion cast of Figure 21b (Zhang. The three vascular layers in the choroid: outer arteries and of the eye and merge with the ophthalmic vein. Corrosion cast of a cut face of the human choroid (59 K jpeg image) (From Zhang, 1994) 7. The human retina is a delicate organization of neurons, glia and nourishing blood vessels. In some eye diseases, the retina becomes damaged or compromised, and degenerative changes set in that eventally lead to serious damage to the nerve cells that carry the vital mesages about the visual image to the brain. We indicate four different conditions where the retina is diseased and blindness may be the end result. Much more information concerning pathology of the whole eye and retina can be found in a website made by eye pathologist Dr. A view of the fundus of the eye and of the retina in a patient who has advanced glaucoma. A view of the fundus of the eye and of the retina in a patient who has age-related macular degeneration. The macular area and fovea become compromised due to the pigment epithelium behind the retina degenerating and forming drusen (white spots, Fig. The cones of the fovea die causing central visual loss so we cannot read or see fine detail. The pressure rises because the anterior chamber of the eye cannot exchange fluid properly by the normal aqueous outflow methods. The pressure within the vitreous chamber rises and compromises the blood vessels of the optic nerve head and eventually the axons of the ganglion cells so that these vital cells die. A view of the fundus of the eye and of the retina in a patient who patient who has advanced diabetic retinopathy. It comes in many forms and consists of large numbers of genetic mutations presently being analysed. The rods of the peripheral retina begin to degenerate in early stages of the disease. Patients become night blind gradually as more and more of the peripheral retina (where the rods reside) becomes damaged. Eventally patients are reduced to tunnel vision with only the fovea spared the disease process. Characteristic pathology is the occurence of black pigment in the peripheral retina and thinned blood vessels at the optic nerve head (Fig. Diabetic retinopathy is a side effect of diabetes that affects the retina and can cause blindness (Fig. The vital nourishing blood vessels of the eye become compromised, distorted and multiply in uncontrollable ways. Laser treatment for stopping blood vessel proliferation and leakage of fluid into the retina, is the commonest treatment at present. R, (1994) Scanning electron-microscopic study of corrosion casts on retinal and choroidal angioarchitecture in man and animals.

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Each behavior/skill below includes a description of skill deficits or examples of behaviors that are associated with autism spectrum disorders acne 10 dpo order accutane now. If available skin care with retinol purchase accutane 30 mg overnight delivery, describe the interaction between the provider and the subjects of the study skin care 2012 order accutane american express. Setting the physical setting in which the intervention or service was administered skin care 5 steps purchase accutane overnight delivery. Comparison Group/Condition the group or condition that the results of the treated group are compared against. The treated group may be compared to a different group of subjects or to the same group pre-intervention. Provider Type & Qualifications the occupation/role, skill sets and/or qualifications of the person or group of people who provided the service or intervention. Provider Training Any training and/or support given to the service provider prior to and/or during the intervention/service. Intervention Intensity The number of hours per day and/or days per week the intervention was administered during the time period provided in the Intervention Duration category. Design the research methodology that was used to assess the effectiveness of the intervention. This will involve reviewing the articles to find out how the group membership (Treatment group vis-a-vis Control/Comparison group) was established. For example, was random assignment (randomization) used to select program participants into the Treatment group and Control group. In this regard, the following represent different types of research designs that provide evidence for interventions. Select the research design that was used by the researchers to evaluate the effectiveness of the intervention. Design Description Randomized designs Randomized, controlled trial (including An experimental design that studies the effect group randomized designs) of an intervention or treatment using at least two groups: one that received the intervention and one that did not; participants are randomly assigned to a group. Group randomized trials with discrepant A randomized design study where different units of analysis, or with an inadequate outcome measures used for the groups. The intervention can be provided by the program developers as long as the investigative team who evaluated the intervention was independent. Outcome List the specific outcomes measures in the study, including Pre/Post or Group Mean Scores. Generalization the extent to which skills acquired in one setting can be carried over to other settings. For example, if the intervention was provided at home, are the children able to apply those skills at school or to other social settings. For example, if the intervention was provided by a teacher, is the subject able to use those skills when with a parent. For example, if the subjects are taught to sort their toys by color, are they able to sort by other rules or in different settings. Maintenance the degree to which the program participants maintain the acquired skills after the intervention is concluded. In this case, the reviewer should indicate the time period beyond which the program effects/impacts are sustained. For example, inadequate sample size, selection bias, and weaknesses of the study design. First, it was established specifically to assess the quality of evidence supporting the 4 Schuerman, J. Second, it offers clear, published definitions for ranking evidence that can be reliably applied to the literature identified for this environmental scan. Third, this ranking system was developed based on international consensus, and represents the state of the field with regard to the meta-analysis of psychosocial and behavioral interventions. During the review process, each study was rated on a 9 point scale based on the rigor of the research design. As presented in Table 2, a rating of 9 was assigned to a randomized, controlled trial, which provides the most rigorous level of evidence; a rating of 1 was assigned to a case study or series, which provides the lowest level of evidence according to the Campbell Criteria. Group randomized trials with discrepant units of analysis, or with 8 an inadequate number of aggregate units assigned to condition Quasi-experimental designs a. The process included multiple components to account for all possible errors that could be made during the review or analysis process. This process was conducted by two reviewers and involved reviewing the entire manuscript and confirming that each entry in the database was correct. During the quality assurance process, any inconsistencies between the entries in the database and the manuscripts were corrected. For example, queries were run in Access to identify and address issues such as missing or inaccurate data. The team adapted the intervention categories and descriptions used in the National Standards Project (described earlier in this report) for use with the environmental scan. Each intervention identified in the environmental scan was aligned with one of the categories based on the descriptions in the reviewed articles. Table 3: Intervention Categories and Descriptions Intervention Description Interventions involving the use of traditional teaching methods Academic Interventions to improve academic performance Interventions involving the modifications of events that typically precede the occurrence of a target behavior. These treatments do not better fit one of the other treatment "packages" in this list nor are they associated with specific treatment programs Interventions that teach individual skills or goals through Music Therapy music Interventions involving using primarily child-directed interactions to teach functional skills in the natural environment. They often focus on providing a stimulating Naturalistic Teaching Strategies environment, modeling how to play, encouraging conversation, providing choices and direct/natural reinforcers, and rewarding reasonable attempts these interventions involve teaching children without disabilities strategies for facilitating play and social Peer Training interactions with children on the autism spectrum. Stories Story-based Intervention Package may be supplemented with additional components. Two high quality experimental or quasi-experimental group design studies, Single-subject design studies. Three different investigators or research groups must have conducted five high quality single subject design studies, or Combination of evidence. One high quality randomized or quasi-experimental group design study and three high quality single subject design studies conducted by at least three different investigators or research groups (across the group and single subject design studies). High quality randomized or quasi-experimental design studies must not have critical design flaws that create confounders to the studies, and the design must allow readers/consumers to rule out competing hypotheses for study findings. High quality in single subject design studies is reflected by a) the absence of critical design flaws that create confounders and b) the 5 demonstration of experimental control at least three times in each study. Each population-specific sub-section includes detailed tables with descriptions of the interventions for each population group and the level of evidence of these interventions. Each table includes a description of the intervention and key information about the intervention, such as the setting where it was implemented, type of providers, provider training, duration, intensity, generalization, maintenance, and number of studies that were reviewed for each intervention. A discussion of the findings is provided for each evidence level by population group. For a detailed explanation of the column titles, please refer to Exhibit 3 (Information Gathering Protocol). Appendix B contains study level information for each of the interventions by population and level. The findings are organized by level of evidence, in order of ranking, beginning with level 1. Within each discussion, we address interventions, their effectiveness, and the targeted behaviors, Table 4 shows the number of interventions that were rated as level 1, level 2, and level 3 based on the rigor of evidence on their efficacy and effectiveness as presented in the reviewed studies. The most common interventions represented in the 157 articles/studies were Behavioral Package (reviews in 32 studies) and Cognitive Behavioral Intervention Package (reviewed in 23 studies). Structured Teaching met the level 1 criterion with only three high quality studies, the lowest amount of evidence provided for the level 1 interventions. The interventions evaluated in this level addressed all six of the target behaviors described in the Information Gathering Protocol. Communication and Social Development were the most common target behaviors addressed. As shown in Table 5, all but one of the interventions were implemented in the home and at school. Teachers and parents are the most common providers in this level, which correlates with the common settings of home and school. Parent and teacher training workshops were used to train the providers in the procedures for implementing the intervention. For example, in many studies, therapists provided training to parents and teachers to enable them to effectively implement the intervention either in the home or school settings. Overall, the studies reviewed for the interventions included in this group had positive outcomes.

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