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  • Associate Professor of Medicine
  • Member of the Duke Cancer Institute
  • Affiliate of the Regeneration Next Initiative

https://medicine.duke.edu/faculty/katherine-schuver-garman-md

Handwriting may in fact be uncomfortable and even painful diabetes oral health forxiga 10 mg otc, as well as emotionally and physically draining for children with Asperger Syndrome diabetes urine test fasting order 5mg forxiga with mastercard. For the student with Asperger Syndrome blood sugar testing for diabetes generic forxiga 5mg free shipping, it is often necessary to separate the creative and the mechanical acts of writing so that the student’s creativity is not hampered by the motor effort required of handwriting. The most common co-morbid condition in adolescents with Asperger Syndrome is depression. Teachers in the middle and high school settings should be particularly aware of the early warning signs of depression in this age group. The steps are as follows: (1) educate yourself; (2) reach out to the parents; (3) prepare the classroom; (4) educate peers and promote social goals; (5) collaborate on the implementation of an educational program; and (6) manage behavioral challenges. Step 1: Educate Yourself As the person responsible for the education and behavior management of all your students, including a child with Asperger Syndrome, you must have a working understanding of Asperger Syndrome and its associated behaviors. When children with Asperger Syndrome do not respond to the use of language or act out in class, it is typically not because they “Students with Asperger Syndrome benefit are ignoring you, trying to clown around, from organization and structure. These behaviors structured environment for the student will not may be more related to their Asperger only provide a better learning environment, but Syndrome, and they may be having also feel more relaxed and competent. It is important to find ways to create a comfortable environment for your students with Asperger Syndrome so that they can participate meaningfully in the classroom. Learning about Asperger Syndrome in general and about the specific characteristics of your student will help you effectively manage this behavior and teach your class. Below are some helpful hints that can guide everyday school life for young people with Asperger Syndrome. They can be applied to individuals with Asperger Syndrome across the school years and are applicable to almost all environments. Provide this time or modify requirements so they can fit in the time allotted and match the student’s pace. Avoid rushing a child with Asperger Syndrome, as this typically results in the child shutting down. When time constraints are added to an already stressful day, the student can become overwhelmed and immobilized. Prepare the child for changes by discussing them in advance, over-viewing a social narrative on the change, or showing a picture of the change. The environment can also be managed by incorporating student preferences that may serve to decrease his or her stress. For example, when going on a field trip, the student might be assigned to sit with a group of preferred peers. Or if the field trip is going to include lunch, the student has access to the menu the day before so he or she can plan what to eat. Additional information is included in the Providing Academic and Environmental Supports section (Appendix B) on page 29. Make a visual schedule that includes daily activities for students with Asperger Syndrome. It is essential that the demands of the daily schedule or certain classes or activities be monitored and restructured, as needed. For example, “free time, ” which is considered fun for typically developing youth, may be challenging for students with Asperger Syndrome because of noise levels, unpredictability of events, and social skills problems. For a child with Asperger Syndrome, free time may have to be structured with prescribed activities to reduce stress and anxiety. A good scheduling strategy is to alternate between preferred and nonpreferred activities with periods in the schedule for downtime. Free time refers to periods during the school day when students are engaged in unstructured activities that have marked social demands and limited teacher supervision. Lunch time, passing time between classes, and time at school before classes actually begin all meet the criteria for free time. Downtime, on the other hand, provides an opportunity for the child or youth with Asperger Syndrome to relax or de-stress.

The expected prevalence rate for Asperger’s syndrome diabetes xmas cards buy forxiga uk, therefore blood glucose fluctuations order generic forxiga online, according to diabetes yeast infections discount forxiga 10mg visa these criteria, would vary between 1 in 33, 000 and 1 in 1200 children. The diagnostic criteria of choice by many clinicians, especially in Europe and Aus tralia, are those of Gillberg and Gillberg (1989) which represent more accurately the original descriptions of Asperger and the profile of abilities of children referred for a diagnostic assessment for Asperger’s syndrome. According to the Gillberg criteria, the prevalence rate is between 36 and 48 per 10, 000 children, or between 1 in 280 or 210 children (Ehlers and Gillberg 1993; Kadesjo, Gillberg and Hagberg 1999). Prev alence figures indicate how many individuals have the condition at a specific point in time, while incidence is the number of new cases occuring in a specified time period, such as one year. Using the Gillberg criteria, it is my clinical opinion that we are cur rently detecting and diagnosing about 50 per cent of children who have Asperger’s syndrome. Those who are not referred for a diagnostic assessment for Asperger’s syndrome are able to camouflage their difficulties and avoid detection, or a clinician fails to see Asperger’s syndrome and focuses on another diagnosis. Since 1992, I have conducted a regular diagnostic assessment clinic for children and adults with Asperger’s syndrome in Brisbane, Australia. A recent analysis of over 1000 diagnostic assessments over 12 years established a ratio of males to females of four to one. From my clinical experience, I have noted that girls with Asperger’s syndrome may be more difficult to recognize and diagnose due to coping and camou flaging mechanisms, which can also be used by some boys. One of the coping mecha nisms is to learn how to act in a social setting, as described by Liane Holliday Willey in her autobiography, Pretending to be Normal (Willey 1999). The clinician perceives someone who appears able to develop a reciprocal conversation and use appropriate affect and gestures during the interaction. However, further investigation and observa tion at school may determine that the child adopts a social role and script, basing her persona on the characteristics of someone who would be reasonably socially skilled in the situation, and using intellectual abilities rather than intuition to determine what to say or do. An example of a camouflaging strategy is to conceal confusion when playing with peers by politely declining invitations to join in until sure of what to do, so as not to make a conspicuous social error. The strategy is to wait, observe carefully, and only par ticipate when sure what to do by imitating what the children have done previously. Girls with Asperger’s syndrome can develop the ability to ‘disappear’ in a large group, being on the periphery of social interaction. There can be other strategies to avoid active participation in class proceedings, such as being well behaved and polite, thus being left alone by teachers and peers; or tactics to passively avoid cooperation and social inclusion at school and at home, as described in a condition known as Pathological Demand Avoidance (Newsom 1983). A girl with Asperger’s syndrome is less likely to be ‘fickle’ or ‘bitchy’ in friendships in comparison to other girls, and is more likely than boys to develop a close friendship with someone who demonstrates a maternal attachment to this socially naive but ‘safe’ girl. These characteristics reduce the likelihood of being identified as having one of the main diagnostic criteria for Asperger’s syndrome, namely a failure to develop peer rela tionships. The girl’s problems with social understanding may only become conspicuous when her friend and mentor moves to another school. The language and cognitive profile of girls with Asperger’s syndrome may be the same as those of boys, but the special interests may not be as idiosyncratic or eccentric as can occur with some boys. Adults may consider there is nothing unusual about a girl who has an interest in horses, but the problem may be the intensity and dominance of the interest in her daily life: the young girl may have moved her mattress into the stable so that she can sleep next to the horse. If her interest is dolls, she may have over 50 Barbie dolls arranged in alphabetical order, but she would rarely include other girls in her doll play. While in conversation with a boy with Asperger’s syndrome, the listener is likely to consider the child a ‘little professor’ who uses an advanced vocabulary for a child of that age, and is able to provide many interesting (or boring) facts. Girls with Asperger’s syndrome can sound like ‘little philosophers’, with an ability to think deeply about social situations. From an early age, girls with Asperger’s syndrome have applied their cognitive skills to analyse social interactions and are more likely than boys with Asperger’s syndrome to discuss the inconsistencies in social conventions and their thoughts on social events. The motor coordination problems of girls may not be so conspicuous in the play ground, and they are less likely to have developed the conduct problems that can prompt a referral for a diagnostic assessment for a boy. Thus, where a girl has developed the ability to conceal her signs of Asperger’s syndrome in the playground and classroom, and even in the diagnostic assessment, then parents, teachers and clinicians may fail to see any conspicuous characteristics of Asperger’s syndrome. At my clinic I see people with Asperger’s syndrome of all ages, and although the sample of adults with Asperger’s syndrome is small in comparison to the number of children, I have noticed that the ratio of men to women with Asperger’s syndrome is almost two to one. Many of the women who seek a diagnostic assessment have previ ously not had the self-confidence or a reason to seek a diagnostic assessment.

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There was an expressed preference to diabetes type 2 fruit forxiga 10mg on line be ‘invisible’ with participants reporting that their physical visibility exposed them to blood glucose kits for dogs buy forxiga with a visa unwanted attentions diabetes mellitus type 2 insulin dependent icd 9 order cheap forxiga online. This consequently led to stresses that impacted learning by taking away any ability to allay anxieties and to ‘focus’. Thus hiding, or seeking out places to be invisible, was a common on-campus activity for participants. Participant 5, a distance education student, likened the online environment to wearing ‘sunglasses’. However, while hiding or screening provided opportunities for relief and for confidence in certain situations there was also the recognition of the need for, and benefits of, engagement at university. There was an expressed desire for social interaction and inclusion enabled by selected degrees of proximity and engagement. One participant spoke of the value of participating passively in the social environment of campus as an opportunity to develop life skills by watching the interactions of others. Participant 4 also spoke of the negative consequences of avoiding campus due to the importance of social engagement as a part of the holistic experience of learning. Working with others, being connected and feeling part of a team was upheld by Participant 4 as an important part of the learning process. There were spaces on campus that promoted this feeling, instilling confidence and motivation, and others that quashed it, leading to feelings of being ‘trapped’ and strategies of avoidance. Participants expressed, both by direct statement and by example, a need for structured but smaller social settings that foster, rather than force, social interaction. The key issue is choice; the provision of experiences that offer opportunity to engage but do not demand it, and that provide options for the means to do so. The cognitive environment encompasses issues related to difficulties in ‘making sense’ of the world. Navigation A key issue discussed by participants was a sense of disorientation in navigating the university including both the academic environment and the built environment. In the academic environment, at a macro level participants reported problems navigating the processes of application and entry to the university and into university courses. The structure of courses themselves coupled with the administrative processes that link them were also problematic. In fact, one participant described how it was ‘the structure of the university’ not the ‘academic content’ that was the cause of his greatest difficulties at the University. Two other participants talked about the difficulties of navigating the Arts degrees and the contrast in subsequently moving to a more highly structured degree in another Faculty. Participants consistently commented on their preference for structure, for requirements and directions to be broken down, literal language used and choices reduced. At a micro level, the navigation of learning materials was also seen as complicated. Inconsistencies with the type of materials and resources required by different courses, and the sheer volume of resources supplied was overwhelming. Even within the context of individual units participants experienced difficulties understanding instructions in learning materials. The ability to keep track of where they were up to in a particular course and to structure personal time management around course requirements caused frustrations. Similarly, navigation of the campus built environment posed difficulties for participants. Structure and spaces assumed to be supportive offered little assistance and direct navigational aids often led to greater confusion. Systems employed on the campus, such as the campus map, were described as being illegible and tended to Owen, McCann, Rayner, Devereaux, Sheehan & Quarmby 53 Supporting students with Autism Spectrum Disorder in Higher Education exacerbate problems rather than aid navigation. Room numbering systems and even the library’s Dewey classification system caused confusion and time wasting and could even result in students missing class. Not only were the processes associated with finding places or things on campus challenging, but confusion about where to go within spaces was also commonly described. Reading or translating navigational clues in the built environment was problematic. For example, when talking about the new cafeteria, Participant 6 noted: ‘It also has two cash register spots and that is confusing’ (diary), and speaking about the new student services centre said: ‘I never know exactly where I’m supposed to line up and wait for staff’ (diary).

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I would have denied that I’m afraid of loud noises what metabolic disease might you see ketonuria order 10mg forxiga amex, that I have a narrow range of interests blood sugar 56 purchase forxiga 10 mg otc, and that I get upset by changes in routine blood glucose abbreviation cheap forxiga master card. If I thought it was good, I would have said yes, and if I thought it was bad, I would have said no. The cognitive processing required gives the impression of a thoughtful rather than spontaneous response. Some adults with clear signs of Asperger’s syndrome may consider that their abili ties are quite normal, using the characteristics of a parent as the model of normal interac tion skills. If the person had a dominant parent with the characteristics of Asperger’s syndrome, this may have influenced the person’s perception of normality. Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superficial social contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity. Even if the person has been told not to talk about their particular obsessive topic for too long, this difficulty may be evident if other topics arise. Frequent tendency to say things without considering the emotional impact on the listener (faux pas). Inability to tell, write or generate spontaneous, unscripted or unplagiarised fiction. Either lack of interest in fiction (written, or drama) appropriate to developmental level or interest in fiction is restricted to its possible basis in fact. I explain to the client and family the concept of a 100-piece diagnostic jigsaw puzzle. When more than 80 pieces are connected, the puzzle is solved and the diagnosis confirmed. None of the characteristics are unique to Asperger’s syndrome, however, and a typical child or adult may have perhaps 10 to 20 pieces or characteristics. The person referred for a diagnostic assessment may have more pieces than occur in the typical population, but sometimes not enough, or the key or corner pieces, to complete the puzzle or receive a diagnosis of Asperger’s syndrome. This term describes someone who has many of the fragments or pieces of the diagnostic jigsaw but some pieces are described as atypical or sub-threshold. However, there are sufficient pieces or fragments of Asperger’s syndrome to warrant recognition that the person is ‘almost there’ and needs access to services for the pieces that are there. Should a diagnosis of Asperger’s syndrome be confirmed (the diagnostic puzzle is completed), the summary at the end of the diagnostic assessment needs to acknowledge the positive characteristics of Asperger’s syndrome such as being an expert in a particu lar field, the degree of expression of each of the main characteristics, the overall degree of expression, and which characteristics in the profile of abilities and behaviour are not due to Asperger’s syndrome. The clinician may also need to comment on the signs of any secondary or dual disorders such as depression, anxiety or conduct disorder, and whether another disorder is currently the dominant factor affecting the person’s quality of life and, as a matter of expediency, should be the priority for treatment. I make an audio recording for the client or his or her family of the summary stage of the diagnostic assessment, so that participants can listen to the explanation several times to absorb all the information and implications. Other family members and teachers who were not able to attend the diagnostic assessment can listen to the recording to aid their understanding of the rationale for the diagnosis. I have also noted that recording the summary can lessen the likelihood of being misunderstood or misquoted when others are informed of the diagnosis and degree of expression. The next stage is to discuss the known causes of Asperger’s syndrome, recommended specific programs, government support services, support groups, relevant publications, the likely prognosis and the monitoring of progress. However, this would be achieved in subsequent appointments once the significance of the diagnosis has been understood and acknowledged. However, we are developing diagnostic assessment procedures that can be used with pre-school children (Perry 2004). Clinicians can include some of the descriptions of the characteristics of very young children with Asperger’s syndrome that are described in subsequent chapters, as part of their assessment procedures for very young children who could be developing the early signs of Asperger’s syndrome. The confidence in the diagnostic assessment of adults can also be affected by the honesty and accuracy in the responses of the client. The person may be able to ‘fake it’ in terms of denying difficulties with social competence, and using intellect in the artificial circumstances of a clinic room to provide the response of a typical adult, but may in fact have conspicuous difficulties in everyday social interaction. There is a difference between knowledge at an intellectual level and actual practice in real life.

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  • https://www.nccn.org/patients/guidelines/content/PDF/distress-patient.pdf
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