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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
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https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

In addition medications with aspirin purchase 20mg pepcid mastercard, patients with epilepsy need scan—that the air or gas has been absorbed top medicine purchase 40 mg pepcid fast delivery. If such to medicine lake california buy on line pepcid be cautious about consuming alcohol before or dur information is not available treatment 02 binh discount pepcid 20mg amex, it is advisable to wait at ing air travel and should be reminded of the importance least 7 d before traveling. Compliance cerebrospinal uid leak from any cause should not y with medication dosage and time schedules should be because of the possibility of backow and microbial emphasized and anticonvulsant medication should be contamination due to the pressure changes within the readily available in carry-on bags (not only in checked cabin (52). Patients who have had a recent cerebral infarction Neuropsychiatry (stroke) or other acute neurological event should be observed until sufcient time has passed to assure sta Neurological and psychiatric disorders of particular bility of the neurological condition. Clearly, the risk of concern for airline passengers are those that might be post-event complications, the physical and mental dis suddenly incapacitating, acutely progressive or de ability, and the decreased capacity to withstand the menting, or that might involve dangerous or disruptive stresses of ight are cogent reasons not to y. Physicians who must decide acute phase of recovery is over and the patient is stable, whether patients with such disorders should travel by travel may be reconsidered. Patients with some neurological or psychiatric disorders become very upset by changes Persons with psychiatric disorders whose behavior is to familiar routines, confusion over procedures, en unpredictable, aggressive, disorganized, disruptive or forced crowding with strangers, or lack of privacy (41). Patients with psychotic What will be the effect upon a patient of such irritants disorders who are stabilized on medication and are as parking, luggage transport, long lines, security accompanied by a knowledgeable companion may be checks that may involve physical searches, confusing able to y. The resulting symp craft delays or missed connections, and other realities of toms may be aggravated by expanding gas volume at air travel If a question arises about the effects of air travel on Physicians should be alert for tendencies toward any patient, particularly those with known neurological claustrophobia and phobias about air travel or interper or psychiatric disorders, physicians may wish to assess sonal crowding. Increased anxiety may manifest itself the mental status of the would-be traveler in a formal in hyperventilation. An anxiolytic medication may be manner, or at least to receive an informed opinion indicated if the patient has used it before with good about the patient’s ability to travel from a knowledge results and without undue side effects. Cognitive airliner in ight is no place to discover that a patient behavioral treatment of fear of ying is effective for reacts to a medication with allergic symptoms, severe many people. Fully detoxify patients diagnosed with drug or alco Keeping these principles in mind, physicians should hol abuse before they travel, in order to avoid inight consider the following specic elements when patients withdrawal reactions. Carefully consider the social fac with neurological or psychiatric conditions wish to y. Neurological A person’s cognitive abilities may be impaired for In general, most patients with epilepsy can y safely. Remember that some patients who should be cautioned about air travel including the at function reasonably well during daylight hours in fa tendant risk of limited medical care capability inight. Patients with epilepsy should be made ings, or during the hours of darkness (“sun-downing”). Because such a crisis could be life-threaten been in the past, and plan for care during travel based ing, such patients should be advised not to travel by air on these “worst-case” circumstances. Sickle cell trait, on the other reliable companion may be all that is necessary for an hand, has not been associated with problems at normal uneventful ight, especially if care is taken to complete cruising altitude. Scuba diving has become a very popular sport with literally hundreds of thousands of people taking diving Miscellaneous Conditions vacations. Because most of these divers y to their destination and return home by air, the relationship Airsickness between ying and diving must be appreciated. This is facilitated by expo ication with oral medications such as phenergan with sure to low barometric pressure (ying) too soon after ephedrine, hyocine, dextroamphetamine, or with a exposure to high barometric pressure (diving) and transdermal scopolamine patch worn behind the ear. Even small amounts difcult because there are few scientic data on the of alcohol can increase sensitivity of the vestibular sys subject (77). Susceptible individuals should avoid alcohol for studies at the Hyperbaric Center at Duke University 24 h prior to as well as during ight. Divers making single dives per diving day should aspiration and its attendant complications. Hence, the have a minimum surface interval of 12 h before ascend patient should be provided with wire cutters in case of ing to altitude. Divers who make multiple dives per day, or over In some cases, it would be advisable to have an escort. Extended surface intervals allow for additional denitrogenation and may reduce the likeli Anemia hood of developing symptoms. For those diving Although there are many types of anemia, advice to heavily during an extended vacation, it is advisable to the traveler is similar for all. In general, special consid take a day off at midweek, or save the last day to buy eration should be given to anyone with a hemoglobin those last-minute souvenirs before taking to the air. Although this is the the best estimate for the majority of divers for a conser recommended standard for air travel, there may be vative, preight surface interval. There will always be individual variability depending upon how well com an occasional diver whose physiological makeup or pensated the anemia is. If there is any question about these are the best recommendations that physicians can suitability to y, medical oxygen should be adminis give travelers who plan to dive and y. Usual Regimen Day of Departure/Travel (East bound) First Day at Destination Multiple injection regimen Usual premeal soluble insulin. If less than 4 hours Return to usual insulin regimen if you have with pre-meal soluble between meals this requires a slightly reduced overcompensated with the reduction of insulin and overnight dose of the third soluble injection (by 1/3) and the evening intermediate insulin. If there are, ying is contraindicated niently given by a pen device, is recommended even if before appropriate treatment (recompression) is carried this does not form part of the usual insulin regimen out. This gives the exibility of allowing the short acting insulin to be administered regularly with each Diabetes meal for the duration of the ight period and can be supplemented by intermediate-acting insulin prior to Overseas travel should not pose signicant problems the rst night’s sleep on arrival at the travel destination. The other advantage of familiarity with the short-acting Preplanning is important and a discussion of the itin insulins is their value in minor illness, such as gastro erary with the diabetic specialist management team enteritis or upper respiratory infection, as an adjunct to plays an important part in the preparation for travel. Those who are being that advice can be obtained from a diabetic specialist treated with insulin should carry an ample supply in team on how to modify the individual’s regimen. The supply of insulin not being used in ight East, the travel day will be shortened and if more than should not be packed in checked baggage as this may be 2 h are lost, it may be necessary to take fewer units of exposed to temperatures which may cause the insulin intermediate or long acting insulin. There is an additional hazard When traveling west, the travel day will be extended that luggage may be mislaid en route. Insulin should be and if it is extended for more than 2 h, it may be carried in hand luggage in a cool bag or precooled necessary to supplement with additional injections of vacuum ask. However, it does not require refrigera soluble insulin or an increased dose of an intermediate tion during ight. The cabin altitude in modern jet aircraft is meals will usually sufce, supplemental snacks may be between 6000 and 8000 ft which should not affect the necessary if meals are delayed. The consequences are most ward ight) just before breakfast (local time), 2/3 of the signicant for those with Type 1 (insulin-dependent usual morning dose of insulin should be taken because diabetes). For those patients with Type 2 diabetes fewer than 24 h will have elapsed since the previous treated with insulin, the endogenous insulin will pro morning’s insulin injection. This adjustment should vide a suitable buffer and compensate to some degree prevent hypoglycemia as a result of extra activity or for deciencies of an insulin regimen. Usual regimen Day of Departure/Travel (West Bound) First Day at Destination Multiple injection regimen Usual premeal soluble insulin. Additional with pre-meal soluble soluble insulin injection with additional meal/ soluble insulin (1/3 of usual morning insulin and overnight snack. Modest reduction (1/3) in overnight dose) should be considered if fasting intermediate insulin. First Morning at Day of Departure 18 hour After Morning Dose Destination Two-dose Usual morning and 1/3 usual dose followed by meal or snack if Usual two doses schedule evening doses blood glucose 14 mmol L 1 Single-dose Usual dose 1/3 usual dose followed by meal or snack if Usual dose schedule blood glucose 14 mmol L 1 On the day of departure, when traveling west across consider alerting cabin crew to the fact that they are ve or more time zones, the diabetic traveler should insulin-using diabetics, and should have readily acces take the usual doses of insulin before breakfast (Table sible identication. During the ight, meals can be eaten according to the Individuals with Type 2 diabetes treated by oral airline schedule. Consultation with the cabin crew on agents should not have the potential problems of the timing of meals may be helpful. Additional doses of tablets are patients check their blood sugar before meals at 4 to usually not required to cover an extended day, al 6-hourly intervals, during the ight. About 18 h after though the use of a drug such as repaglinide may be the morning injection of insulin, regardless of whether valuable to cover an additional meal. A dose of the the patient is still in ight or at the destination, blood normal hypoglycemic agent may have to be omitted glucose should be tested again. If the blood glucose is on a truncated day in the case of a long west-to-east 1 1 14 mmol L (250 mg dl) or less, the individual may air journey. How discuss the proposed journey with their diabetic spe 1 ever, if the blood glucose is greater than 14 mmol L, cialist adviser.

Diseases

  • Cormier Rustin Munnich syndrome
  • Aniridia ataxia renal agenesis psychomotor retardation
  • Familial partial epilepsy with variable focus
  • Xeroderma pigmentosum, type 1
  • Hypertelorism and tetralogy of Fallot
  • Nemaline myopathy

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Indiana met the Healthy People 2020 Goal for children less than 5 years of age in 2011 with an incidence rate of 9 medicine used to treat bv order 40 mg pepcid amex. Indiana did not meet the Healthy People 2020 Goal for adults aged 65 years and older; the incidence rate for this population was 42 symptoms quiz purchase cheap pepcid on-line. Two additional Healthy People 2020 goals examine the rate of penicillin resistant invasive Streptococcus pneumoniae medications 4 times a day order pepcid amex. The Healthy People 2020 goal for penicillin resistant invasive pneumococcal disease is 3 cases per 100 treatment 5th metacarpal fracture 20 mg pepcid visa,000 population for children under age 5 years and 2 cases penicillin resistant cases per 100,000 population for adults aged 65 years and older. Epidemiology and Trends In 2012, 727 cases of pneumococcal disease were reported in Indiana for a case rate of 11. Table 1: Pneumococcal Disease Case Rate by Race and Sex, Indiana, 2012 2008 2012 Cases Rate* Total Indiana 727 11. In 2012, 82 counties reported at least one case, and 41 counties reported 5 or more cases of invasive pneumococcal disease (Figure 4). The incidence rates were highest among the following counties reporting five or more cases: Tipton (31. Figure 4: Pneumococcal Disease Cases by County Indiana, 2012 Steuben St Joseph Elkhart LaGrange 14. Of the 37 cases under the age of 5 years, 35 had viable isolates that were sent to the Indiana State Department of Health for serotyping. You can learn more about pneumococcal infections by visiting the following Web site. Cases can be asymptomatic, experience mild gastrointestinal infection, meningitis, or in the most severe cases, exhibit acute flaccid paralysis. While transmission of wild poliovirus has been interrupted in most of the world, polio transmission has never been interrupted in Afghanistan, Nigeria, and Pakistan. Further spread of the illness into other unvaccinated groups is possible due to international travel. The virus enters the environment through feces and throat secretions of infected people and then is passed to others, especially in environments where hygiene is poor. Public Health Significance Approximately 95 percent of polio infections are asymptomatic, resulting in the ability to spread undetected unless confirmed by laboratory analysis. Once it is introduced into largely unvaccinated populations, polio spreads easily. Poliomyelitis reporting serves to: 1) detect importation of wild poliovirus into the U. Due to the severity of this potentially paralytic disease, timely reporting of suspected cases is extremely important. Disease reporting by clinicians is often delayed because it is only after other differential diagnoses are ruled out that the diagnosis of poliomyelitis is considered. Efforts should be made to promote physicians’ awareness of the importance of prompt reporting of suspected cases to the state and local health departments, as well as the need to obtain stool and serum specimens early in the course of the disease. Polio is still endemic in Afghanistan, Nigeria, and Pakistan, and has re established transmission in some African countries, such as Somalia and Kenya. Humans acquire the disease through inhalation of dried secretions from infected birds. Wild and domestic birds are the natural reservoirs of this agent and are most often involved in transmission to humans. Cattle, sheep, goats, and cats can also become infected with a mammalian strain and develop severe debilitating disease. Large outbreaks of psittacosis in humans have been associated with infected feces and respiratory excretions from domestic poultry flocks. Public Health Significance Human symptoms of psittacosis include fever, nonproductive cough, headache, and malaise. More severe illness may result in heart inflammation, hepatitis, and encephalopathy. Groups most at risk for contracting psittacosis are bird owners, pet shop employees, and veterinarians. Psittacosis can be diagnosed with serum antibody tests and treated with antibiotics. Epidemiology and Trends There were no reported cases of psittacosis in Indiana during the five-year period 2008-2012. You can learn more about psittacosis by visiting the following Web site. Ticks are the primary reservoir and maintain disease cycles in rodents, other mammals, and birds. Cattle, sheep, and goats can carry the infection without signs or symptoms and shed high levels of bacteria when birthing. The bacteria are highly resistant to natural degradation and can persist in the environment for weeks to months. Q fever may result from infection by a single organism, and the low infectious dose enhances transmission efficiency. Human infections generally occur through inhalation of aerosols from contaminated barnyard dust, handling of birthing products from shedding animals, or drinking unpasteurized milk. Humans may have an asymptomatic, acute, mild, or severe disease that can be highly fatal or result in chronic infection that can cause significant morbidity if untreated. Public Health Significance Symptoms of Q fever usually appear 2-3 weeks after exposure and can include high fever, severe headache, muscle aches, chills, nausea and vomiting, and a non-productive cough. Treatment is most effective when initiated within the first three days of illness. People most at risk of becoming infected with Q fever are veterinarians, meat processing plant workers, livestock handlers, and dairy farmers. Q fever is classified as a Category B potential bioterrorism agent* because of its ability to cause infection with a low number of organisms, resistance to environmental degradation, and the ability to cause infection via aerosolization. Epidemiology and Trends No cases of Q fever were reported and confirmed in Indiana in 2012. One case was reported and confirmed during the five year reporting period from 2008-2012. Within the Lyssavirus genus, a number of other viruses have been identified that infect mammalian hosts (animal and human) causing fatal encephalitis. Rabies virus is the lyssavirus associated with rabies in bats and terrestrial mammals around the world. Other lyssaviruses have been identified in bats in Europe, Africa, Asia, and Australia. Rabies is transmitted from animal to animal through transfer of virus-contaminated saliva by bites or mucous-membrane exposures. In Indiana, the North Central Skunk virus and numerous bat subtypes of rabies virus have been identified in the past. In 2012, 6162 cases of animal rabies and one human case were reported to the Centers for Disease Control and Prevention from 49 states and Puerto Rico (Hawaii is the only state that is considered rabies free). Public Health Significance In humans, early symptoms of rabies infection are non-specific but may be similar to influenza (the flu) and may include headache, fever, and malaise. As the disease rapidly progresses, symptoms include numbness/tingling at the site of the bite, anxiety, confusion, hallucinations, excessive salivation, and difficulty swallowing. The virus infects the central nervous system resulting in death, often within days of symptom onset. Rabies post-exposure prophylaxis is available in the form of immunoglobulin and vaccination. Treatment has not been shown to be effective if given after the development of clinical signs; the vaccine must be given before clinical signs develop. Although anyone can be at risk for rabies, people who work with rabies virus in research laboratories and vaccine production facilities are at the highest risk. Other groups at risk include veterinarians, animal control and wildlife officers, rehabilitation specialists, and bat handlers. Epidemiology and Trends Rabies is a rare disease of humans in the United States; no human cases were reported in Indiana in 2012. In the five-year reporting period from 2008-2012, one human case of rabies was reported in Indiana.

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Scatter the cards on the floor and get the young person to medication 3 checks order pepcid 40 mg on-line think about their own strengths and to medications given for migraines buy 40 mg pepcid overnight delivery put the cards into three lists – Definitely medications made from plants buy pepcid mastercard, Mostly and Sometimes medicine journey purchase 40 mg pepcid. Write the lists down or take a photo of the lists, then type or write up to make a poster that the young person can keep. Skills Cards the skills listed over the next few pages can be photocopied and cut out to form individual cards. Start by asking the young person to pick put some skills that they have and write these down in a list. These are both good activities to do with children who seem to have low self-esteem, of find it difficult to talk positively about themselves. The activity is suitable for most ages, although for younger children some words need to be removed or replaced. A variation / extension to this could be to take a few of their skills and illustrate the word, with pictures that say something about themselves. It would also be interesting for young people to explain when they have demonstrated this strength. This means young people are focusing on real examples of when they have done something they are proud of and will hopefully be more aware of their strengths and skills when doing other activities, and will notice more examples of when they exhibit these skills in the future. By Kate Townsend & Paula Chalkley Attendance Support Workers One thing I’d like to be better at is. Feelings Cards these cards can be used in many different situations, either with groups or with individuals. They can be used as an activity to discuss feelings, before going on to problem-solving activities such as Stop and Think! Some of the feelings cards are not necessary when working with younger children, so it is a good idea to select some cards to use with the group. It is ideal for using with secondary age pupils, particularly those with limited emotional literacy. Some suggestions for facilitating discussions: • Ask students to pick two cards that they want to discuss • Ask students to pick out a card of a word they don’t understand • Pick five cards randomly and discuss • Ask students to group the cards in a way which they think is logical and explain why they have grouped them that way. Ask questions of students along the lines of “Can you think of a time when you have felt. If this is being used as groupwork, a trusting atmosphere needs to exist within the group for people to feel able to talk about themselves and their feelings. Feelings Faces these cards have been designed with primary aged children in mind to be used for the purpose of discussing vocabulary around feelings. If to be used as a game, they could be used as “snap”, discussing each feeling as “snap” is achieved. Doing this as a group is beneficial as it allows students to discuss while being distracted by the task. Gather together magazines and newspapers, and ask students to cut out pictures or words of things they enjoy doing, places they have been, careers they desire etc, and create a collage about themselves. Once they have finished, they write their name on the back of the collage, and then other students can guess whose collage is whose. This is a simple and informative activity, useful to encourage discussion about similarities and differences between groups of young people, particularly when the group do not all know each other well. Ranking Traits Ask students to rip a piece of paper into ten strips, and write on each strip a characteristic of their personality, both positive and negative. The students then arrange the pieces of paper in order of what they most like about themselves and what they dislike. Students can be asked to give up their traits one by one, and then discuss which one they will take back and why. This encourages students to think about their personality as a whole, and how things they view as a negative. The “quieter” children who would sometimes go unnoticed are given an equal opportunity to be noticed. Their privilege is to take the register etc and they are first choice for all jobs and privileges. The children should try and use as many different words as they can when describing their classmates, which has the added benefit of being a prompt to use in their writing! Adapted from an idea by Anne Lawrence, teacher Fantasy Island Group Activity Divide a piece of paper into segments according to how many people are in the group. For example, one person may add an airport but would they let anyone else add a road that goes from one part of the island to another This activity can encourage collaboration and discussion as to what is important to individuals and as a group as a whole. A version of this can also be used as a one-to-one activity – see sheet in the One-to-One Activities section. This activity is suitable for students of all ages from primary right through to adult. It can be an enjoyable and very interesting activity, particularly if the leader/facilitator explains only the minimum to get the activity going. It is interesting to see which members of the group assume that the island can cooperate and interact and who sees themselves as pitted against the other members of the island! By Rob Kirkwood Primary Mental Health Worker Shipwrecked this group activity can be used to assist in encouraging and where necessary improve communication skills. It can also help with assertiveness skills as the individual needs to put their point of view across in such as to persuade the other group members to their way of thinking. You need to swim back to your boat to recover the following items that will help you survive on the island: • Compass • Matches • Pint of water • Blanket • Hammer • Radio • String • Knife 1. By Alan Longhurst Attendance Team Manager Speaking Without Words this activity can be used with a group as a tool to discuss feelings and how they may be portrayed. The individuals should then complete the grid before the group is bought together to discuss their findings. This would be good to do with groups of young people who have a low level of emotional literacy, or who find it difficult to talk about feelings. This is suitable for a range of ages, from primary to year 10 or 11 secondary students. This will help to develop the ability to identify those feelings in young people and their friends and to know what that feeling is called. Human beings have many different ways of communicating their feelings without necessarily having to use the spoken word. We give clear messages to others by the way we stand or sit by our movements, through our eyes and by the tone of our voice. Look through newspaper photographs and study the faces and positions of the people caught by the camera. Have a go at filling in the grid below; trying to work out how we are able to tell the particular mood that somebody is in. They then help each other tape the piece of paper to each other’s back (name not to be showing). Using washable markers, each person goes round writing something positive about that person on their back. The group are then encouraged to read the comments made about all of the individuals before they are invited to attempt to work out which one is theirs. All of the papers are then turned over and the individuals find their own paper and can celebrate what has been “said behind their back”. It is important to model this activity prior to it being completed and stress that only positive comments should be made. The first person writes their name on a piece of paper and passes it to the next person in the circle who writes a positive comment about that person. This action is continued until everyone has had comments written about him or her. Adapted from an idea from “Working With Others” University of Brighton 2007 Assertiveness – Four Sheets the first 3 activities can be used on their own or as a series, but the fourth activity probably needs some introduction, by doing one or all of the other activities first. In small groups, students read the situation and decide what your response would be.

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Negative affect is the physical representation of children’s emotions that are either fat or incongruent to symptoms tracker buy cheap pepcid 40mg on line their play symptoms meaning purchase pepcid 20mg with amex. For example medications known to cause seizures pepcid 20mg amex, after the 9/11 terrorist attacks treatment plan for ptsd best purchase for pepcid, children built towers out of blocks and then knocked them over with toy planes. Their affect was completely fat, showing no emotion while playing out what had to be a terrifying event. Research strongly supports the fact that children with interpersonal trauma do play differ ently from other children. Findling and colleagues (2006) compared two treatment groups of children receiving play therapy, one group presenting with a history of interpersonal trauma and the other group presenting with other concerns. The researchers defned interpersonal trauma as trauma involving the interpersonal loss of trust in a signifcant caregiver through abandonment or abuse. Myers, Bratton, Findling, and Hagen (2011) continued this study with the addition of a normally developing group with no known history of interpersonal trauma who were receiv ing play sessions. The researchers omitted repetitive play because the raters were blind to the children’s histories and this inhibited their ability to determine the literalness of the play and whether the play was posttraumatic, mastery, or self-grounding. Perry and Szalavitz (2006) proposed that recovery from childhood interpersonal trauma requires the rebuilding of trust, regaining of conf dence, returning of security, and reconnecting to love. Bratton (2004) added that children need to release and regulate emotions and gain or regain a sense of mastery, coping, and competence. Play therapists can best meet these needs by including reparative experiences in the therapeutic relationship (Benedict, 2006; Bratton, 2004). Four approaches that meet the needs of children with interpersonal trauma in developmentally responsive and relationship-based approaches are child-centered play therapy (Landreth, 2012), child–parent relationship training (Landreth & Bratton, 2006), Cognitive-Behavioral Play Therapy (Cavett & Drewes, 2012), Ecosystemic Play Therapy (O’Connor, 2007), and trauma-focused integrated play therapy (Gil, 2011a). As a student of Rogers, Axline applied Rogers’s (1957) nondirective principles of empathy, genuineness, and unconditional positive regard in her work with children. The philosophy involves a deep and abiding belief in the constructive, self-directing ability of children (Landreth & Sweeney, 1997). Guerney believed many children’s problems resulted when parents lacked parenting knowledge and skills (Landreth & Bratton, 2006). Originally, Guerney would meet parents weekly for about a year, but later reduced the treatment time down to 5 or 6 months. Landreth (Landreth & Bratton, 2006) saw a need for a more streamlined and structured approach that still provided parents with skills they needed but within a time frame to which parents would be comfortable committing themselves. Parents learn the skills of refective listening, recognizing their children’s feelings, self-esteem building, tracking, and therapeutic limit-setting. Of particular importance in working with children who have experienced abuse or neglect is the common experience of betrayal, harm, loss, or rejection by a caregiver. By enhancing the caregiver–child relationship, caregivers are able to establish or reinforce a healthy attachment and safe place for their children. O’Connor (2007) reported the possibility that child survivors of abuse who are treated in nondirective play therapy approaches may be in therapy for extended periods of a half year or more without ever approaching content in their play or engaging in any verbalizations related to their traumatic experiences. He contended these children might become overly comfortable with therapy and adapt to avoiding their feelings and thoughts related to the trauma rather than more actively coping and recovering. The use of the word “ecosystemic” indicates the importance of considering the interaction of the child and all of the systems in which he or she is embedded when conceptualizing the child’s diffculties and developing a treatment plan (O’Connor, 2007). It is based on her years of working with child survivors of traumatic experiences. Gil emphasized the importance of breaking the cycles of denial and secrecy, correcting traumatic memories to decrease posttrauma symptoms, encouraging improved social interactions, and preventing the need for unhealthy coping strategies. For example, the behaviors of these children are often survivalresponses they have learned either to avoid abuse or to control it. Ziegler (2002) stated some abused children push their abusers into abusive action as a way of relieving the tension of always being on guard. Con ducting play therapy with this population requires a number of considerations and modifcations. First, play therapists working with children in interpersonal training need to have a solid foundation in play therapy and a strong understanding of interpersonal trauma and the effects on children. Third, play therapists need to be self-aware, particularly of their own issues related to interpersonal trauma. Children who have experienced interpersonal trauma bring emotionally laden experiences and stories into the therapeutic session, and these may trigger something within the clinician. Play therapists who have worked through their own similar issues in counseling or supervision reduce the likelihood of overidentifcation with their child clients and countertransference. And, last, because child abuse, neglect, and other crimes against children can raise strong emotions in the play therapists who work with them, it is necessary to seek supervision and consultation, or even counseling, periodically. The characteristics of a child survivor are an important consideration in determining the course of treatment. A cen tral goal in working with this population is repairing shattered relationships with signifcant others, if possible. Depending on the severity of damage to those relationships, a child may be better suited for an approach that directly focuses on repairing relationships, such as child–parent relationship training or Theraplay1 (Jernberg & Booth, 1999; Landreth & Bratton, 2006). How ever, sometimes a child’s presenting behaviors may be so severe the play therapist may determine that working with the child and the parent together from the beginning may be overwhelm ing for the parent and/or the child. In such cases, the therapist may choose to work with the child one-on-one in an approach like child-centered play therapy, Ecosystemic Play Therapy, or trauma-focused integrated play therapy. Another important consideration is determining the appropriateness of including children with a history of sexual abuse in group play therapy. While group play therapy can be benefcial for these children, it is important to ensure none of the children are acting out sexually in order to protect all of the children in the group. Again, an initial period of one-on-one play therapy may be useful in preparing children to beneft from group work. While the specifcs of these concerns may vary between approaches, there are some common threads. Children with interpersonal trauma may come from chaotic environments, and need predictability and stability in order to reestablish a sense of safety. Play therapists provide predictability and stability through the way they are in the playroom and the way they structure the play session and the playroom. Play therapists provide a nurturing and supportive environ ment for children through caring acceptance of the child and through being consistent and predictable in their being with the child (Landreth, 2012). Play therapists provide predictability in the playroom by grouping toys according to the emotions they typically engender. Toys serve as a child’s words in play therapy; when children are unable to fnd the toys they need to express themselves, it is analogous to when adults have trouble fnding a right word. Play therapists also need to consider the duration and frequency of the play sessions. Developmentally, younger children (ages 3 to 6 years) may be able to attend to the therapeutic process for only 30 minutes, whereas older children may be comfortable with 45 to 50 minute sessions. Traditionally, play therapy sessions occur once a week; however, some children may need more or less frequent play sessions. For example, children living in a domestic violence or homeless shelter may require frequent ses sions because the period of time during which they will be able to access treatment may be short as their living arrangements change. On the other hand, children who are approaching the end of treatment may start to meet every two weeks or once a month in preparing for termination while still receiving support. Play therapy theories have various views on how play therapists approach intakes, assessments, and treatment planning. Regardless of theoretical approach, play therapists need to have an understanding of a child’s personal and trauma history, as well as the child’s relationship with caregivers. With child survivors of interpersonal trauma, play therapists need to be aware of the type of interpersonal trauma and the nature of the relationship between the child, caregivers, and trauma. Understanding how a child experienced the trauma and caregivers, particularly if a caregiver was a perpetrator of the trauma, provides play therapists with important insight in understanding a child’s play, planning treatment, and accessing change and growth. Child survivors of interpersonal trauma need reparative experiences to regain their innate ability and potential. There are number of specifc techniques/strategies to consider in meeting the needs of children of interpersonal trauma.

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