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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Meningococcal disease is the leading infectious cause of death in early childhood impotence 40 years buy cialis sublingual 20mg line, making its control a priority for clinical management (as well as public health surveillance and control) erectile dysfunction statistics canada discount 20mg cialis sublingual visa. The epidemiology of bacterial meningitis in Ireland has changed dramatically in the past two decades following the introduction of vaccines to erectile dysfunction trials generic cialis sublingual 20 mg mastercard control Hib disease jack3d causes erectile dysfunction cialis sublingual 20 mg fast delivery, serogroup C meningococcus and some types of pneumococcus. Meningitis caused by other bacteria is discussed in the epidemiology section of this document. Public health measures relating to Hib and pneumococcal disease are outlined in the document but public health measures for other bacteria causing meningitis are not discussed in this document as public health measures are not usually required for such diseases. Meningitis or encephalitis caused by viruses and related guidance is under review and will be presented in a separate document. Other notifable diseases causing meningitis are also notifable as soon as possible. Septicaemia is often characterised by a rapidly evolving petechial or purpuric rash that does not blanch under pressure. However, in the early stage of development the rash may blanch with pressure thus resembling a viral rash, or it may be absent, or may be atypical. If present it may consist only of a few haemorrhagic spots located in a place such as the groin or feet. Septicaemia, with or without meningitis, can be particularly severe and is associated with a considerably greater mortality rate than meningococcal meningitis without bloodstream infection. The development of signs suggestive of acute sepsis and/or meningitis is a medical emergency and mandates prompt intervention. Acute meningococcal disease, the most common cause of life threatening infection in healthy children and young adults, commonly presents as severe sepsis and/or meningitis. The overall mortality rate for meningococcal infection typically ranges from 3-10%, but can reach as high as 20-40% in severe sepsis/meningitis (see Chapter 5 for further detail). Meningococcal infection remains the most common cause of bacterial meningitis in Ireland. The speed with which meningococcal infections are recognized and treated is critical to achieving a successful outcome and clinical suspicion alone mandates treatment. Although results of studies of the beneft of pre-admission antibiotics have been inconsistent, this has variably been attributed to their retrospective nature and confounding factors such as illness severity (those most severely ill may be more likely to receive antibiotics). In -17 Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) the early stage of development the rash may blanch with pressure thus resembling a viral rash. The rash can appear rapidly on any part of the body including the palms and soles. The petechial rash presents as discrete 1 to 2 mm in diameter lesions that may proceed to form larger ecchymotic lesions. The rash commonly appears in clusters in areas where pressure occurs from elastic in underwear and stockings. The rash may go unnoticed unless the acutely unwell patient with a systemic febrile illness is completely undressed so that a thorough search for a haemorrhagic rash can be undertaken. Less commonly, the rash has a maculopapular appearance, with the discrete pink macules or papules blanching under pressure. The authors found that: • leg pain • cold extremities • and abnormal skin colour were frequently seen in the frst 12 hours of meningococcal disease (median onset 7-12 hours). More recently in 2011 the authors reported fve “red fag symptoms”: • confusion • leg pain • photophobia • rash and • neck pain/stiffness. In this study cold hands and feet had limited diagnostic value, while headache, and pale colour did not discriminate meningococcal disease in children. These symptoms and signs however, can be non-specifc and some may be present with other bacterial and viral infections including self-limiting viral illnesses. Primary meningococcal conjunctivitis may be associated with invasive disease and should be treated systemically. Immediate administration of benzylpenicillin to suspected cases of meningococcal septicaemia by general practitioners was associated with reduced mortality in three retrospective studies in England. However, if general practitioners or advanced paramedics are unable to access the intravenous route, it is appropriate to administer benzylpenicillin by the intramuscular route. A clear history of proven penicillin anaphylaxis is a contraindication to use of penicillin or cephalosporins. Recommendation All general practitioners or advanced paramedics should have benzylpenicillin available in their surgeries and emergency bags and should be ready to administer it without delay to a patient with an acute systemic febrile illness and a petechial or purpuric rash. It is particularly important that this should be done if a person shows signs of sepsis or decreased level of consciousness. However, if available, a third generation cephalosporin (ceftriaxone 80 mg/kg/dose, max 2g or cefotaxime 50 mg/kg/dose, max 2g) can be used and is an acceptable alternative to benzylpenicillin for the empirical treatment of suspected meningococcal disease prior to transfer to hospital. The ambulance service needs to be informed of the immediate and critical nature of the transfer. Recommendation It is strongly recommended that any patient with an acute systemic febrile illness be referred immediately to hospital if any of the following are present: • a haemorrhagic rash • an impaired level of consciousness • signs of meningeal irritation • clinical features not normally expected in children with acute self limiting systemic febrile illnesses or • the patient is a close contact of someone who was recently diagnosed as having meningococcal disease even if the current patient received clearance antibiotics. Clinical notes accompanying the patient should inform the hospital clinician about antibiotics that have been administered (and dose). In both scenarios it is imperative that appropriate antimicrobials are given as soon as the diagnosis of sepsis Acute meningococcal disease, the most common cause of life threatening infection in healthy children and young adults, commonly presents as severe sepsis and/or meningitis. The overall mortality rate for meningococcal infection is approximately 3-10%, but can reach as high as 20-40% in severe sepsis/meningitis. In a review of 407 children in Ireland, with meningococcal infection who survived to hospital admission between 1995 and 2000, the overall mortality rate was 3. Serogroup B isolates account for the overwhelming majority of cases now diagnosed in Ireland. The speed with which meningococcal infections are recognized and treated is critical to achieving a -20 Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) successful outcome and clinical suspicion alone mandates treatment. Although results of studies of the beneft of pre-admission antibiotics have been inconsistent,22-24 this has variably been attributed to their retrospective nature and confounding factors such as by illness severity (those most severely ill may be more likely to receive antibiotics). The incidence of Hib meningitis declined steeply following the introduction of this Hib vaccine. Lumbar puncture should be carried out if the patient is haemodynamically stable and there are no contraindications 12. Add vancomycin if there is concern regarding possibility of beta-lactam resistant pneumococci. They are unlikely to be of beneft if given more Minimise neurologic sequelae than 24 hours after antibiotic therapy has been and prevent deafness commenced Dexamethasone phosphate 0. Reduce oxygen consumption In the unstable child, intubation is a prerequisite for inter-hospital transfer. If considering Maintain inspiratory plateau insertion of a central line, intubate frst <30cm for adults and <25cm (regardless of level of consciousness). Hypoglycaemia should be treated with 5ml/ kg of 10% dextrose solution and subsequent inclusion of dextrose in maintenance fuids Maintain K+ within normal Assess K+ needs as soon as U&E results range available 13. Of critical importance in era of introduction of ‘meningitis Throat swab a full sweep of the pharyngeal vaccines’ wall and tonsils, from all patients. If not possible, obtain a pernasal swab rotated on the posterior pharyngeal wall 14. Early orthopaedic input if required (for fasciotomy), plastic surgery if required 15. Ensure Contact Chemoprophylaxis if this is the responsibility of the admitting team. All telephone notifcations must necessary (See Chapter 7, 8, 9, Appendix be followed by written notifcation. For patients who are unresponsive to fuid and inotrope resuscitation give low dose steroids 12. Single Dose (Adult dose) cefotaxime 50 mg/kg 50 mg/kg 50 mg/kg 2g or or or ceftriaxone Not in 80 mg/kg 80 mg/kg 2g neonates amoxicillin* 100 mg/kg 50 mg/kg 2g gentamicin* 2. Add vancomycin if there is concern re possibility of beta-lactam resistant pneumococci. Urine output > 1ml/kg/hr Start immediately with Hartmann’s, normal saline, or colloid.

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Primary adrenal insufficiency can result from glandular destruction or metabolic failure yellow 5 impotence order generic cialis sublingual. Secondary adrenal insufficiency erectile dysfunction drugs nz cialis sublingual 20 mg otc, more common than the primary form erectile dysfunction natural treatments order cialis sublingual now, can result from hypopituitarism associated with hypothalamic pituitary disease erectile dysfunction in young men discount cialis sublingual 20mg otc, or from suppression of the hypothalamic-pituitary axis by exogenous 36,37 steroids or endogenous steroids, such as a tumor. Adrenal crisis can result from an acute exacerbation of chronic insufficiency, usually caused by sepsis or surgical stress. Hydrocortisone, 100 mg intravenously every 6 hours, and fludrocortisone ac etate (mineralocorticoid), 0. The key management 38 principle is treatment of the underlying problem that precipitates the crisis. It occurs in susceptible individuals who have abnormal regulation of calcium in skeletal muscle. This defect allows large quantities of calcium to be released from the sarcoplasmic reticulum of skeletal mus cle, causing a hypermetabolic state. The hypermetabolic response leads to increased production of carbon dioxide, metabolic and respiratory acidosis, accelerated oxygen consumption, heat production, activation of the sympathetic nervous system, hyper kalemia, disseminated intravascular coagulation, and multiorgan dysfunction and fail 39 ure. Early clinical signs of malignant hyperthermia include a rapid, exponential increase in end-tidal carbon dioxide, muscle rigidity, tachypnea, tachycardia, hyper kalemia, and fever. Early diagnosis, supportive care with ventilatory and 40 circulatory support, and treatment with dantrolene can improve the outcome. Patients at highest risk are those Fever in the Postoperative Patient 1053 with prostatic disease, those who have received spinal anesthesia, and those who have undergone anorectal surgery. When presenting signs and symptoms are particularly severe, a diagnosis of pyelonephritis or intra-abdominal 30 infectious complication should be considered. Pneumonia Almost all surgical patients are at increased risk for postoperative pneumonia. Exposure to mechanical 44 ventilation, even for a short duration, increases the risk of pneumonia. The depressed mental status induced by general anesthesia makes patients susceptible to aspiration if they vomit. Catheter-Related Bloodstream Infections In the United States, patients in intensive care units log 15 million central vascular 46,47 catheter days every year. The use of peripheral, mid, and central catheters puts patients at increased risk for bloodstream infections and insertion-site–specific infections such as thrombophlebitis. The clinician should have a low threshold for removing presumptively infected indwelling catheters early in the course of treatment, espe cially when disseminated infection is suspected. If the patient’s temperature elevation and leukocytosis do 30 not resolve within 24 hours after removal, antibiotics should be considered. Infected Prosthetics Procedures that involve placement of prosthetic material such as orthopedic hard ware, neurosurgical ventriculoperitoneal shunts, abdominal mesh, or vascular grafting can all result in complicated surgical infections. The emergency medicine provider must recognize the prosthetic as a potential source of infection. Infection from sternal wires or a surgical-site infection on the sternum can result in devastating complications such as mediastinitis. Meningitis can occur after neurosurgical procedures or after placement of an intra 30 cranial drain or monitor. Clostridium difficile Infections Enteric infections caused by Clostridium difficile are increasing in prevalence and resistance. Twenty percent to 50% of hospitalized patients are colonized 30,53 with the organism. Risk factors for fulminant toxic megacolon or clinically signifi cant infection include disruption of the normal colonic flora, exposure to an antibiotic, 30 chemotherapy, and inflammatory bowel disease. Fecal transplantation and a new macrolide antibi otic, fidaxomicin (Dificid), are newer treatment modalities directed against more resis 54 tant strains. Life-threatening or potentially life threatening causes of the fever should be given diagnostic and treatment priority. Early consultation with the operative/procedure team can clarify the diagnostic approach and target management. A postprocedure fever algorithm can help emer gency care providers through key decision making. Timely use of broad spectrum antibiotics can help prevent the patient from progressing on the continuum of fever to multisystem organ dysfunction. After culture results have been obtained, the antibiotic regimen should be reviewed to stem the development of resistant organisms. For emer gency medicine providers, it is imperative that the evaluation take into consideration both noninfectious and infectious causes (Table 5). A clear understanding of the timing of the onset of fever in relation to the procedure (immediate, acute, subacute, or delayed) can differentiate likely diagnoses. A thorough history and physical exam ination are mandatory and will guide further diagnostic workup. Source control remains the ultimate goal in patients found to have septic foci such as an abscess. Should we measure body temperature for patients who have recently undergone surgery Open versus laparoscopic cholecystectomy: a comparison of postoperative temperature. Natural history, relationship to postpericardiotomy syndrome, and a prospective study of therapy with indomethacin versus pla cebo. Necrotizing soft tissue infec tions: delayed surgical treatment is associated with increased number of surgi cal debridements and morbidity. Pulmonary embolism and fever: when should right-sided infective endocarditis be considered Preoperative pulmonary risk stratifica tion for noncardiothoracic surgery: systematic review for the American College of Physicians. Nosocomial infections in surgical pa tients in the United States, January 1986-June 1992. Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes. The incidence and factors associated with graft infection after aortic aneurysm repair. Clostridium difficile testing in the clinical laboratory by use of multiple testing algorithms. The editor takes no responsibility for the content of Intranet links referenced in the Grey Book. If the patient is pregnant, discuss management with the duty obstetric registrar as soon as possible. During the working day, or when on in-take, refer upwards through your own medical firm. If on “cover” at night and you need advice about a patient on another firm and there is no policy written in the notes, first turn to the in-taking registrar and then to the patient’s own consultant. If the patient’s consultant cannot be contacted, refer next to the registrar/senior registrar and finally to the in-taking consultant. As the defibrillator is charged, warn all rescuers other than the individual doing chest compressions to “stand clear”. Once the defibrillator is charged, tell the rescuer performing chest compressions to “stand clear”. The interval between stopping compressions and delivering a shock must be minimised and not exceed a few seconds (ideally <5s). Longer interruptions to chest compressions reduce the chance of a shock restoring spontaneous circulation. Precordial thump: A precordial thump has very low success rate for cardioversion of a shockable rhythm and is only likely to succeed if given within few seconds of the onset of a shockable rhythm. It is therefore appropriate only when several clinicians are present at a witnessed, monitored arrest, and when a defibrillator is not immediately to hand. A precordial thump should be undertaken immediately after confirmation of cardiac arrest and only by healthcare professionals trained in the technique. Using the ulnar edge of a tightly clenched fist, deliver a sharp impact to the lower half of the sternum from a height of ~20 cm, then retract immediately to create an impulse-like stimulus.

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Thus erectile dysfunction milkshake cheap 20mg cialis sublingual mastercard, it has been claimed that we will never be able to erectile dysfunction and premature ejaculation buy cialis sublingual 20mg without prescription solve the problem of other minds unless we understand that the body of the other differs radically from inani mate objects impotence education purchase 20mg cialis sublingual with visa, and that our perception of this body is quite unlike our ordinary perception of objects erectile dysfunction treatments diabetes order cialis sublingual canada. To be more specific, empathy has typically been taken to constitute a unique form of intentionality, and one of the phenomenological tasks has conse quently been to clarify its precise structure and to spell out the difference between it and other forms of intentionality, such as perception, imagin ation and recollection. A number of investigations have also been concerned with the way in which the very intentional relation between subjectivity and world might be influenced by intersubjectivity. It has been argued that a fundamental feature of those objects we first and foremost encounter in our daily life, namely artefacts, all contain references to other persons. Be it because they are produced by others, or because the work we are trying to accomplish with them is destined for others. Thus, in our daily life we are constantly embedded in an intersubjective framework regardless of whether or not there are de facto any others persons present. In fact, the very world we live in is from the very start given to us as already explored and structured by others. We typically understand the world (and ourselves) through a traditional con ventionality. We participate in a communal tradition, which through a chain of generations stretches back into a dim past: ``I am what I am as an heir' [41]. In short, the world we are living in is a public and communal world, not a private one. Subjectivity and world are internally related, and since the structure of this world contains essential references to others, subjectivity cannot be understood except as inhabiting a world that it necessarily shares with others. Moreover, this world is experienced as objective, and the notion of objectivity is intimately linked with the notion of intersubjectivity. That which in principle is incapable of being experienced by others cannot be ascribed reality and objectivity. To put it differently, the objectivity of the world is intersubjectively constituted, and my experience of the world as objective is mediated by my experience of and interaction with other world-engaged subjects. Only insofar as I experience that others experience the same objects as myself, do I really experience these objects as objective and real. Consciousness does not consist of separable, substantial (``thing-like') components, exerting a mechanical±efficient causality on each other. Rather, the phenomenological concept of consciousness implies a meaningful net work of interdependent moments. These views have import ant implications for psychopathological taxonomic endeavor. First, examination of single cases, as already pointed out by Jaspers, is very important. Reports from few patients, able to describe their experi ences in detail, may be more informative of the nature of the disorder than big N studies performed in a crude, simplified way. Subjective experience or first-person perspective, by its very nature, cannot be averaged, except at the cost of heavy informational loss. In other words, in-depth study of anomalous experience should serve as a complement to strictly empirical designs. But even the latter may be dramatically improved, if the psycho pathological examinations are phenomenologically informed. Second, a psychiatrist, in his diagnostic efforts, is always engaged in what is called a ``typification' process [43, 44]. At the most elementary level, typification simply implies ``seeing as', the fact that we always perceive the world perspectivally, i. The most frequent type of typification is the pre-reflective and automatic one, linked to the corporeal awareness, and this holds for the diagnostic encoun ter as well. But we can also engage in reflective attitudes in order to make our typifications more explicit. The notion of typicality or of a prototype is crucial here: it is a notion important in all cognitive research [46±48]. Most cognitive and epistemic categories are founded upon a ``family resemblance', a network of criss-crossing analogies between the individual members of a category [29], with very characteristic cases occupying central position, and less typical cases forming a continuum towards the border of the category, where the latter eventually blends into other, neighboring categories. This is also explicitly the case in the statistical detections of syndromatic entities. However, phenomenology would argue that the psychiatric typifications sedimented through encoun ters with patients are not only a matter of simple averaging over time of the accumulated atomistic sensory experiences, but are also motivated by a quest for meaningful interrelations between the observed phenomenal fea tures. Ideal type exemplifies the ideal and necessary connections between its composing features. Phenomenological approach to anomalous experience is precisely con cerned with bringing forth the typical, and ideally necessary features of such experience. This is the aim of the eidetic reduction: to disclose the essential structure of the experience under investigation by means of an imaginative variation. This variation should be understood as a kind of conceptual analysis where we attempt to imagine the phenomenon as being different from how it currently is. This process of imaginative vari ation will lead us to certain borders that cannot be varied, i. The variation consequently allows us to distinguish between the accidental properties, i. It is important not to confuse this claim with the claim that we can obtain infallible insights into the essence of every object whatsoever by means of some passive gaze. On the contrary, the eidetic variation is a demanding conceptual analysis that in many cases is defeasible. The aim of psychopathological phenomenological analysis will be to dis close the essential, invariant properties of abnormal phenomena. The same will be the case at the level of diagnostic entities: these are seen by phenomenology as certain typical modes of human experience and existence, possessing a meaningful whole reflected in their invariant phenomenological structures. Delimitation ofA A diagnostic entities is supported by a concept of a whole or an organizing Gestalt (Ganzheitsschau) [51]. As a phenomenon autism manifests itself, it expresses a certain fundamentally altered mode of existence and experience [52±53], which may serve to delimit schizophrenia as a disease concept. It is likely that the altered form of experience is, pathogenetically speaking, closer to its natural/biological substrate; the content is always contingent and idiosyn cratic because it is mainly, but not only, biographically determined. There fore, formal alterations of experience will be of a more direct taxonomic interest. It is on this point that phenomenology offers a method called phenomeno logical reduction, that is a specific kind of reflection enabling our access to the structures of subjectivity. It is a procedure that involves a shift of attitude, the shift from a natural attitude to a phenomenological attitude. In the natural attitude, that is pre-philosophically, we take it for granted that there exists a mind-, experience-, and theory-independent reality. But reality is not simply a brute fact, but a system of validity and meaning that needs subjectivity, i. Thus, a phenomenological analysis of the object qua its appearing necessarily also takes subjectivity into account. Insofar as we are confronted with the appearance of an object, that is with an object as presented, perceived, judged, evaluated, etc. We are led to the acts of presentation, perception, judgement and valuation, and thereby to the subject that the object as appearing must necessarily be understood in relation to. We do not simply focus on the phenomenon exactly as it is given, we also focus on the subjective side of consciousness, and thereby become aware of the formal structures of sub jectivity that are at play in order for the phenomenon to appear as it does. The subjective structures we thereby encounter are the structures that are the condition of possibility for appearance as such. A subjectivity which remains hidden as long as we are absorbed in the commonsensical natural attitude, where we live in self-oblivion among the objects, but which the phenomenological reduction is capable of revealing. Formal configuration of experience includes modes and structures of intentionality, spatial aspects of experience, temporality, embodiment, modes of altered self-awareness, etc. However, as we have already argued, in order to address these formal or structural aspects of anomalous ex perience, the psychiatrist must be familiar with the basic organization of phenomenal awareness. Otherwise he would only have a superficial, com monsensical take on experience at his disposal.

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MineCraft became a way for Katelyn to erectile dysfunction xanax discount cialis sublingual 20mg with mastercard communicate her thoughts and feelings to vegetable causes erectile dysfunction buy cialis sublingual 20mg cheap her mother and step-father during subsequent family play sessions erectile dysfunction early 20s 20 mg cialis sublingual for sale. As a result erectile dysfunction yoga exercises order cialis sublingual from india, her mother and step-father joined her in MineCraft play, which helped them understand her and build a relationship with her. As play therapists look to the future of play therapy, it is certain technology will play a role. Children and adolescents are drawn to the imaginative and creative tools created by the advances in technology. It is important for play therapists to learn to utilize technological devices, and the games and apps played on those devices, and to make sure the child’s needs are being addressed through this powerful medium. Play therapists need not fear the changes technology may bring, but instead should commit to learning and growing along with the amazing young people with whom they work. The Sims in therapy: An examination of feasibility and potential of the use of game-based learning in clinical practice. The Narcissus myth, resplendent refections, and self-healing: A Jungian perspective on counseling a child with Asperger’s syndrome. Computer/video games as a play therapy tool in reducing emotional disturbances in chil dren. Dissertation Abstracts International: Section B: the Sciences and Engineering, Vol 70(12-B), 2010, 7854. Play therapy and asperger’s syndrome: Helping children and adolescents grow, connect, and heal through the art of play. Group therapy techniques with children, adolescents, and adults on the autism spectrum: Growth and connection for all ages. Computerized cognitive behavioral therapy for the prevention and treatment of depression and anxiety in children and adolescents: A systematic review. Taking the sand tray high tech: Using the Sims as a therapeutic tool in the treatment of adolescents. Outcomes for youth with serious emotional disturbance in secondary school and early adulthood. However, there are gaps in the literature regarding the use of play therapy; specifcally, there is a need for research demonstrating play therapy is an empirically supported treatment. Continued efforts to conduct research are necessary to the development, refnement, and applicability of play therapy. Treatment interventions evolve over time to meet the needs of the current culture. Over the years, researchers in play therapy have explored the structure, theoretical constructs, delivery format, and effect of play therapy in accordance with contemporary standards of research design and methods. In order for play therapy to thrive, researchers must repeatedly offer evidence to support intervention, monitor changes in protocol implementation, and develop theoretical constructs for intervention. The purpose of this chapter is to provide the play therapy researcher and practitioner with an overview of research methods that are viewed as credible and correspond to the nature of play therapy intervention. We will present the basics of each method, discuss its compatibility with play therapy, and provide examples from the play therapy literature when available. We seek to provide play therapists with ideas to help in the implementation of research design in order promote the intervention of play therapy, especially as an empirically supported treatment. Fur thermore, the designs we present will help practitioners enhance their play therapy through a more thorough understanding of how play therapy works. In addition, practitioners can utilize research to promote their practice, understand processes within play therapy, and demonstrate their effectiveness with supervisors, parents, and prospective clients. Knowledge and comprehension of theoretical constructs related to the play therapy modality being employed Research requires the isolation of variables affecting the outcome of therapy. In order for a researcher to identify such variables, there should be a deep understanding of constructs that serve as a basis for change for the play therapy modality being used. Questions a play therapist needs to ask before embarking on the construction of research may include: What is the mechanism of change for the type of play therapy being used Clinical experience Because the implementation of play therapy in research design can be challenged with thera peutic and ethical issues, relevant clinical practice is essential for the play therapist researcher. During a research study, the therapeutic care of each child is prioritized over all research project goals; hence, the researcher’s practitioner role becomes fundamental in implementation of the design. In addition, Himelein and Putnam (2001) warned that when researchers do not practice, there is a stronger probability the research is divorced from real-world needs and concerns. Basic to extensive knowledge of research design Regardless of the type of research design used, a play therapist researcher should be well trained in the implementation of that design. Formal education in research design is a preferred qualif cation, and prior membership in research teams is helpful. Knowledge of the appropriate use of statistical analyses Although it is not necessary for play therapist researchers to be experts in statistics, they should have ample knowledge of statisticalapproaches for their chosen designs. More complicated exper imental designs require advanced statistical knowledge, while single case designs tend to utilize simpler statistical analysis. Formal training, membership on research teams, and continued edu cation opportunities are benefcial to increasing statistical knowledge and application. Although these qualifcations appear daunting, we encourage play therapists to seek addi tional training and practice experiences to improve their research and statistical knowledge. Some research designs are easily conceptualized, and play therapists may fnd themselves more competent and interested than they expected. Online educational opportunities have increased over the last decade, allowing for greater opportunities for learning. Initiated as an effort to ensure quality services to clients, this movement has fragmented in multiple directions, leaving most researchers scrambling to Pthomegroup Methodologies Suited to the Study of Play Therapy 633 determine current criteria needed for quality studies. Criteria for empirically supportedtreatments continually change and are interpreted differently by organizations and government agencies. Although criteria for this label can be unclear, most researchers agree that a multiplicity of designs, when conducted with rigor, can potentially offer evidentiary support for a treatment intervention. We provide two examples of criteria found in the literature that highlight different perspectives in reviewing evidence-based literature. Nathan and Gorman (2007) provided standards to evaluate intervention according to “methodological adequacy of the research studies from which the outcome data were derived” (p. They suggested there are six types of studies ranging from most to least rigorous. Criteria for type 1 studies include comparison groups with random assignment, blinded assessments, clear inclusion and exclusion criteria, strict diagnostic methods, adequate sample size, and detailed statistical methods. Type 2 studies involve clinical trials, yet they have some faws that prevent a type 1 designation. None of the faws of a type 2 study is considered fatal, and these studies offer substantial contributions to the literature. Type 3 studies have signifcant methodological faws and are typically open treatment studies that focus on the collection of pilot data. Type 3 studies provide information regarding the worth of the treatment in pursuing a more rigorous design. Type 6 studies are of marginal value and include reports such as case studies, essays, and opinion papers. In an effort to help practitioners identify treatments that are empirically supported in real-world settings, Rubin and Bellamy (2012) proposed an alternate structure for determining the effectiveness of interventions. They identify systematic reviews and meta-analyses as level 1 studies in the research hierarchy, citing replication of a single intervention as being the most credible source of evidence. Level 3 studies are individual randomized experiments, and level 4 studies are quasi-experimental, characterized by the nonrandomization of participants. At level 6, correlational studies provide evidence of relationship but do not allow for causal inferences. Level 7 studies include case studies, single group pre-/posttest studies, and qualitative studies. The structures provided by Nathan and Gorman (2007) and Rubin and Bellamy (2012) emphasize the variations and commonalities in the current state of evidence-based reviews. However, many research designs are considered valuable in the understanding of how an intervention works.

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