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The following clues may indicate that the child is having difficulties with the subject: behavior changes diabetes and erectile dysfunction causes buy malegra dxt plus paypal, including distracting or avoidant behavior; attempts to erectile dysfunction 5-htp generic malegra dxt plus 160mg free shipping change the topic of conversation; somatic complaints; complaints of boredom; or change in affect erectile dysfunction treatment houston tx order malegra dxt plus 160 mg line. The therapeutic experience can be organized so that it does not overwhelm or exhaust the child. Some ways in which the therapeutic session can be structured are as follows: Examine one aspect of the abuse at a time. Identifying and attending to life experiences that were not abusive or neglectful is also an important part of therapy. This helps the child place the harmful experience in context and shows that maltreatment is only one of many factors or experiences that has impacted his/her life. The child then can identify skills and arenas that he/she is competent enough to manage or master. Focusing on both positive and negative experiences can enhance the childs sense of self. Attending to life experiences that do not include being abused helps the child expand his/her sense of self and identity. This allows the child to integrate the experience into an overall sense of self that is not based solely on victimization. It also initiates the grief process that many children need to experience in order to let go of old images, expectations, behaviors, and feelings. Resistance Many behaviors that are initially perceived as resistance are really behaviors that are geared to monitor and manage anxiety generated by recall of the abuse experience. Fidgeting, fooling around, interrupting, asking inappropriate questions, and straying from the topic or task all need to be considered as possible coping behaviors that help a child disengage from his/her painful feelings and thoughts generated by the abuse. The ego defenses or defensive maneuvers that a child uses to protect him/herself from overwhelming stimuli or memories related to the abuse experience need to be acknowledged and used so the child feels validated, capable, and able to survive in the best way he/she knows how. A child seldom lets go of a defense mechanism, a defensive shield, or protective maneuver simply because he/she is told to do so. Tailoring interventions that facilitate the childs ability to process the experience and manage the anxiety and stress that are generated are important. A child will change his/her behavior when he/she feels capable of managing his/her world without that behavior. A child who is not willing to participate in therapy will not benefit from the therapeutic experience. However, there are many ways to help a child feel more comfortable about participating in therapy. These include the following: empathizing with the childs frustration or fears about therapy; clarifying therapy and what will happen, including providing information that therapy does not mean the child is crazy; setting goals that are useful to the child; and 48 contracting for a certain number of sessions with the option to continue counseling if necessary. It is important to note, however, that not all resistant behavior means the child is unwilling to participate in therapy. Furthermore, the child may not understand what is expected of him/her within the therapeutic relationship. The child will benefit from clear descriptions of the purpose and benefits of therapy as well as clarification of how to think about and respond to questions, including the options of not knowing or not wanting to say (yet). The clinician should also explore any fears or concerns that the child might have about therapy. Developing a format for the session, clarifying the use of time within the session and attending to content and process experiences are important in effective therapy. Format Developing a format or routine for the therapeutic session allows the child to accomplish the tasks of remembering, talking about the abuse, and discharging accumulated emotions. The format helps the child organize his/her thoughts, feelings, and behavior and feel comfortable about discharging his/her emotions, exploring their circumstances and history, and learning how the abuse has affected him/her. It is important to clarify the topics that will be covered, such as What happened to you, and how you feel about it The therapist can tell the child that his/her role as therapist is to help the child with any questions or concerns he/she might have about the abuse. This allows the child to begin to expect help from the therapist and to challenge the therapist when the child does not feel that the therapist is being useful. Use of Time Most therapy is organized within a specific time frame, usually the therapeutic hour. Within this time frame the therapist needs to accomplish the following: reestablishing rapport and exploring current issues with the child, addressing issues relevant to abuse or neglect, making the therapy relevant to the childs daily life, exploring the childs feelings about the therapeutic experience, and providing closure on the therapeutic experience. The therapist and child need enough time to reestablish rapport, catch up on what has happened during the week, discuss and evaluate the work done in the last session, address current issues relevant to the childs growth and development, discuss and explore issues relevant to the abuse or neglect, and generate closure so the child can 49 function effectively after completion of the therapeutic session.

Therapists must take care to erectile dysfunction pills cvs order malegra dxt plus with american express communicate a welcoming erectile dysfunction without drugs buy discount malegra dxt plus 160 mg on-line, inviting stance from the moment children open the door to impotence remedy discount malegra dxt plus 160mg mastercard the offce until they leave. There are many opportunities to display mindfulness about cultural diversity with art work hanging on the walls or the literature in the waiting room magazine rack. Other simple ways to communicate cultural sensitivity are by picking music, fabrics, or images in details such as accent pillows. These are small but concrete ways to be mindful of diversity issues and broaden the welcome to children from all backgrounds. Hinman (2003) notes, Decorations that convey beliefs in the perspectives of many cultures may serve to encourage the ethnic minority client to explore these dimensions of their lives (p. The play therapy offce is also a place of therapist-to-child communication, verbally or non verbally. Therapists communicate how they feel about play therapy and children in general by the care they take in setting up their offces and the purposeful or less careful ways they choose the toys in their rooms. Play therapists include different types of toys, although most adhere to a list of toys created early in the development of the feld (Axline, 1981; Landreth, 2002). In addi tion to toys, it is important that play therapists consider the art materials presented to children, to ensure many skin tone colors are available. For those therapists who utilize sand therapy work with children, it is similarly important to consider the selection of miniatures. Traditionally, sand therapists tend to introduce their sand therapy collections by referring to their collections as including symbols of everything in life (Homeyer & Sweeney, 2010). A typical collection includes categories of sand tray miniatures that attempt to be all-inclusive. For example, for the broad category animals, there is inclusion of prehistoric, wild, domesticated, and fantasy animals. Other categories include minerals (rocks, fossils), vegetation (plants, rocks, cacti), buildings, transportation objects (cars, planes, boats), people, spiritual symbols, and elements of earth, fre, air, and water. Historically, cross-cultural toys have been diffcult to identify and obtain, which is perhaps a refection of supply and demand. Here are several examples: An 8-year-old African-American boy says, My mom says Spanish people are sneaky and rob people. I dont hang out with him because Id knock him out if he tried to do weird stuff with me. Some therapists might elect to overlook or ignore the comment as a childs passing statement, others may simply refect, and some may feel it is critical to guide the conversation or provide psychoeducation. Hortensia, the child in the introductory vignette, clearly introduced racist views into the therapy session. If a child is bullied by a child of a different culture, it is possiblethat fear or concern will develop about other children who share that culture. The Role of the Clinician in Responding to Prejudiced Comments and Behaviors In responding to prejudiced statements or behaviors, therapists can choose anywhere along the continuum from a refective stance to a more direct educational or exploratory position. How therapists respond, and whether responses are made directly to children or to caregivers, must always be carefully considered. We suggest that clinicians be introspective when they are con fronted with statements such as those listed. Some of these commentaries refer to social justice issues, but most of them are based in prejudices, stereotypes, or racism. Her placement was with an immigrant Korean family of fve: father, mother, and three young children under the age of 5. Horten sia was angry about being removed and worried about her mother; she had taken the role Pthomegroup Issues of Culture and Diversity in Play Therapy 607 of her mothers caretaker in a classic role reversal. However, in foster care, she was incred ibly disrespectful to her foster parents, and she pushed and shoved the younger children in the home. It seemed as if she was trying to get herself kicked out of foster care, believ ing she would be sent home again. Her foster parents were uniquely patient and exhibited great compassion toward her. During the intake with Hortensia and her foster parents, the ways she was fghting the placement and remaining fercely loyal to her mother were candidly discussed.

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Figure 4 shows acute hepatitis B incidence rates by age group per 100 erectile dysfunction treatment photos discount 160mg malegra dxt plus with visa,000 population erectile dysfunction - 5 natural remedies buy discount malegra dxt plus 160 mg online. In Indiana erectile dysfunction medication samples proven 160 mg malegra dxt plus, as well as nationally, higher rates of hepatitis B disease continue among adults, particularly males 30-39 and 40-49 years of age, and persons with identified risk factors (ie. This data emphasizes the need to vaccinate adults and provide preventative counseling, especially for those who are at higher risk for acquiring hepatitis B infection. Table 2 highlights the identified risk factors in 2012 for the acute hepatitis B cases in Indiana. Hepatitis B Risk Factors Indiana, 2012 Risk Factor Number of Cases (Percent of Cases) Multiple Sex Partners 22 (25. The incidence rates, per 100,000 population, were highest among the following counties reporting five or more cases: Monroe (3. Figure 5 shows acute hepatitis B incidence rates by county per 100,000 population. Individuals with chronic hepatitis B infection may be asymptomatic and unaware of their infection for many years before developing clinical evidence of illness. Serologic testing identifies infected persons, allowing for treatment and the identification and vaccination of their contacts. In 2012 the testing and reporting of the hepatitis B status of refugees residing in Indiana continued, especially in Marion and Allen counties where Refugee Centers are located. Infections may range from mild illness lasting several weeks to serious, lifelong illness. The number of reported cases is determined by the number of positive hepatitis C tests reported for the first time during a given year. Acute cases were reportable in 2012, but data is also collected and reported on chronic cases in order to assess risk factors when feasible. Reporting positive test results for hepatitis C virus was not required in Indiana until October, 2000. Investigation of chronic hepatitis C cases contributes to the reduction in the spread of disease by increasing the percentage of persons aware they have a hepatitis C infection and educating infected individuals. The campaign was designed to raise increased awareness about hepatitis C, which is now considered a silent epidemic in the United States. Baby boomers were targeted in particular because they are five times more likely to be infected with hepatitis C than other adults. More information about the campaign, including resources and tools, (fact sheets, posters, multi media information) can be seen by going to. The number of acute cases of hepatitis C increased from 87 cases in 2011 to 112 cases in 2012. Between 15 to 20 percent of these acute cases will spontaneously clear the virus and individuals will no longer be considered infected. The remaining infected individuals may be asymptomatic for years or even decades, becoming chronic cases. Symptoms that may be present during infection include abdominal pain, fatigue, fever, joint pain, jaundice, loss of appetite, dark urine, light stool, nausea, and/or vomiting. Populations most at risk include injection drug users and recipients of blood transfusions and organ transplants prior to 1992. Twenty percent of cases will develop serious liver damage from hepatitis C, and 25 percent of those will need a liver transplant, develop liver cancer, or die. Antibodies can be found in 7 out of 10 persons when symptoms begin and in 9 out of 10 people within three months after symptoms begin. New treatments with higher success rates than those seen in previous years have been developed. However these treatments often carry adverse side effects of their own and can be very costly. New treatment technologies available and their duration of use should be discussed thoroughly with a health care provider. With these continuing partnerships, effective management strategies for hepatitis C can be realized. These organizations include: Aspire Indiana, Corizon, the Aliveness Project of Northwest Indiana and Positive Link. Reporting Requirements In 2012, the case definition for acute hepatitis C was changed.

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This information can be conveyed through childrens storybooks (Holmes buy generic erectile dysfunction drugs order malegra dxt plus line, 2000; Shephard erectile dysfunction vacuum generic malegra dxt plus 160 mg online, 1998) and puppet shows created to where to buy erectile dysfunction pump order cheap malegra dxt plus line address local concerns. For example, after the 2004 tsunami, Sri Lankan teachers were distressed that some children refused to play outside for fear that another tsunami would come. Play therapists developed a puppet show that explained this as a normal response and reminded them how to look at physical evidence to determine when another tsunami is imminent (Baggerly, 2006). Manage hyperarousal Some children experience ongoing hyperarousal in their bodies because they are unable to deac tivate their fght or fight responses after a disaster (Perry et al. As a result, many children have general agitation and may avoid reminders of the disaster, such as being near the water, in an attempt to manage their anxiety. Play therapists should teach children self-soothing, relax ation techniques to calm their bodies. These procedures include (a) taking deep breathes through playful activities, such as blowing soap bubbles or pinwheels; (b) progressive muscle relaxation by tensing like a tin man and relaxing like a rag doll; (c) focusing on positive images by drawing happy places, engaging in mutual story-telling with a positive ending, or meditating on peaceful places; and (d) teaching parents and guardians to conduct soothing sessions that might include massaging, rocking, and singing to their children (Felix et al. For example, in Sri Lanka, many children were afraid to go to the beach after the tsunami. Play therapists taught children and teachers deep breathing and positive images through the following song, which is to the tune of Twinkle, Twinkle, Little Star: I am safe and I am strong. Gradually, children returned to the beach to help with chores of fshing and clothes washing. Manage intrusive reexperiencing Some children experience intrusive thoughts of disaster-related events because brain alterations during a trauma encode indelible pictures in their implicit memories (van der Kolk, 2007). Play therapists should teach children methods of containing these images and grounding themselves. These procedures include: (a) changing the tape by replacing the thought with a predetermined song, story, or saying, such as Im safe right now and I know it because I have. Play therapists can also amend the 3-2-1 sensory grounding and containment procedure (Baranowsky et al. For this game, ask children to identify three objects above eye level, three sounds everyone can hear, and three things they can touch; then two things they see, hear, and touch; followed by one thing they see, hear, and touch. Implementing this activity with children in Hurricane Katrina shelters helped them refocus on the here and now as well as to realize their surroundings were safe (Baggerly, 2006). Increase accurate cognitions Due to their egocentric and concrete cognitions, some children may have misattributions of the cause of disasters, such as their bad dreams or someones bad behavior. Play therapists should assess misattributions and give accurate or at least alternative explanations. In Sri Lanka, play therapists performed a puppet show in which a small puppet timidly asked if the tsunami was caused by bad dreams or by someone putting something in the ocean, while a larger puppet calmly explained that an earthquake under the water caused the tsunami (Baggerly, 2006). Increase effective coping Young children have not had the life experience to develop a wide range of coping strategies and do not have the cognitive ability to accurately evaluate the effectiveness of their coping strate gies. Because negative coping strategies of social withdrawal and self-blame have been correlated with increased depressive symptoms (LaGreca et al. Matching childrens preferred coping styles (attenders who focus on the stim ulus versus distractors who focus away from the stimulus) with corresponding interventions has been shown to be more effective in decreasing symptoms (LaGreca, 2008). Procedures to increase effective coping include: (a) writing or drawing maladaptive coping strategies on cards and telling children to pass the trash; (b) playing card games in which chil dren fnd pairs of adaptive coping strategies and throw out maladaptive strategies; (c) playing coping charades, in which children act out positive coping strategies; and (d) organizing devel opmentally appropriate, cooperative play or games, such as duck, duck, goose and relay races (Felix et al. For example, after the Oklahoma tornados, play therapists guided children in making a coping bracelet of fve colorful cards on which they drew effective coping strategies. Seeking social support Many young children socially withdraw or cling to their parents after a disaster. Some older children withdraw from healthy social support by engaging in disruptive behavior with peers or dissociating via video games. Play therapists should teach children appropriate ways of seeking healthy social support and decreasing unhealthy social withdrawal. For example, after Hurricane Katrina, some children were angrily demanding adults play with them, so play therapists helped the children role-play ways to politely ask for adults to play (Baggerly, 2006). Foster hope When disasters destroy homes, schools, communities, and lives of loved ones, children lose their framework for safety, order, and meaning.

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