Reflection on Nursing Presentation

Reflection on Nursing Presentation REFLECTION ON MY PRESENTATION Presentation: As a major aspect of my abroad program I needed to convey a 15 minutes introduction on decision of subject before my partners. A powerful introduction utilizes the connection between the moderator and the crowd. It takes full thought of the audience’s needs so as to catch their advantage, build up their comprehension, move their certainty and accomplish the presenter’s targets (University of Leicester, 2009). As per Nickolas (2003), to encourage a powerful introduction there are four components. They are: Planning, Preparation, Practicing, Presenting Arranging: it incorporates choice of a significant theme, finding the learning results, sorting out the substance, setting up the visuals. Readiness: The fundamental point is to get ready clear, straightforward and alluring visuals. For eg: successful force point slides. Rehearsing: Practice makes flawlessness it incorporates practice and pre practice. In practice rehearsing the things you are mean doing, however in pre practice rehearsing the things you may need to do. Introducing: It incorporates outward appearance, pace, voice, body developments, utilization of pointer, jobs etc†¦ So as to compose a reflection I chose Gibbs 1988 model. It is principally utilized by wellbeing experts. To reflect isn't sufficient, you at that point need to incorporate the learning and new understanding you have picked up in this way permitting the intelligent procedure to illuminate your training. Making a move is the key; Gibbs prompts the expert to figure an activity plan. This empowers the intelligent professional to take a gander at their training and see what they would change later on, how they would create/improve their training (Gibbs, 1988). It has got six unique stages. Which are portrayal, feeling ,assessment, investigation, end and activity plan. Depiction: As a component of my abroad nursing program I needed to convey a 15 minutes introduction on decision of subject on the last day at college. On my time of arranging I was extremely befuddled about the choice of subject. Assortment of themes was in my brain. At long last I chose my theme which was percutaneous endoscopic gastrostomy taking care of and the consideration of patient with PEG. I was truly fulfilled when I chose the point. Since I felt it will be a significant and helpful data for all the medical caretakers in their work place. Introductory time of my activity in this nation have gone over patients with PEG tube. It was another experience for me. After the determination of my point I began doing some examination on it. I read a few books, diaries, and gathered data from web search tools. Proof based practice characterize as ‘ the faithful, express and reasonable utilization of current best proof in settling on nursing choices about the consideration of individual patients’ (Sackett, 1996). As it is a critical thinking way to deal with the today’s social insurance framework, it brings better clinical choices and patient result. So as to make my introduction progressively viable and clear I chose to utilize some visuals, this was power point slides. My slides were straightforward and straightforward. When I completed my planning I began to rehearse. I rehearsed before my family just to lessen the stage dread. At the day of introduction I was certain enough to introduce before a gathering. Feeling: So as to change the time our gathering was isolated in to two. I was the third individual in the principal gathering. On the day I was marginally apprehensive particularly a couple of moments minutes before the introduction begins. Luckily I felt sure at the hour of introduction and the associates were extremely steady and responsive which expanded my solace level with in the class. Presently I feel , by doing this introduction helped me to accomplish a significant ability in my calling, as showing has a functioning part in nursing. Assessment: International Center for Alcohol Policies (2014) says Evaluation offers an approach to decide if an activity has been beneficial as far as conveying what was planned and anticipated. It has a significant job to improve own aptitudes. After my introduction I moved toward my guide and she gave me an extremely viable and clear criticism. She clarified my points, learning results, presentation of introduction was unmistakably expressed. I utilized proper guides and the conveyance of introduction was fitting, and it was proof based as well. Where I could improve was the time the board as I was minimal short on my time. Investigation: As indicated by Ritchey, (1996) Analysis is characterized as the system by which we separate a scholarly or significant entire into parts or segments. After my introduction I have experienced my experience indeed and I felt my determination of subject was directly as I saw my associates appreciated the point. In any case, I was somewhat disillusioned as I was somewhat short on my time. At the point when I was rehearsing at home I ensured I was on schedule. With this introduction I comprehended the significance of arranging and sorting out the work just as time the executives. End: I discovered it myself the open door I got from the abroad nursing program was extremely extraordinary. Instructing before a gathering of individuals was an upsetting activity for me. At the point when I understood I needed to do it I went after for the level best and the criticism from my mentor made me progressively solid. Medical caretaker has a significant job in showing the staff. In my future profession I will be increasingly sure to show individuals , on the grounds that I got that, it will expand my insight also. Activity plan: I will do another introduction in my work place seeing moving and taking care of as we have numerous new staff begun. Before I do it I will ensure I will arrive at my expected time limit. In addition that, I will experience understanding materials and set up the substance from proof based information. This segment I am intending to do it with a blend of hypothesis and down to earth. I will show them the various kinds of derricks, slings and how to utilize it. It will be increasingly more obvious the moving and dealing with strategy. Clinging to NMC code (2008) I will refresh my insight and abilities all through my profession. References: Gibbs, G. (1988). Learning by Doing: a manual for instructing and learning techniques. London: Further Education Unit. Nickolas, F (2003). Successful introductions, separation counseling: www.nickols.uk (Last got to on 04/02/2014) NMC(2008) The code. http://www.nmc-uk.org/Documents/Guidance/NMC-Guidance-on-proficient lead for-nursing-and-birthing assistance students.PDF (Last got to on 10/01/2014). Universal Center for Alcohol Policies (2014) What Is Evaluation. Online.(Last got to on 24/02/2014) . http://www.icap.org/PolicyTools/Toolkits/EvaluationToolkit/2WhatIsEvaluation/tabid/441/Default.aspx Ritchey T, (1996) On Scientific Method Based on a Study by Bernhard Riemann. Investigation and Synthesis. Online.(Last got to on 20/02/2014) http://swemorph.com/pdf/anaeng-r.pdf Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B. what's more, Richardson, W.S. (1996) ‘Evidence based medication: What it is and what it isn’t’, British Medical Journal. College of Leicester (2009) Planning a successful introduction. Learning improvement .on the web. (Keep going got to on 10/02/2014). http://www2.le.ac.uk/workplaces/ld/assets/pdfs-of-study-guides/introduction abilities pdfs/arranging introduction v1.0.pdf. R PhilipPage 1 Reflection on Nursing Presentation Reflection on Nursing Presentation Working in the careful ward involves various obligations regarding a social insurance professional like me. Considering the comprehensive consideration, recuperation of patients and limiting any inconveniences from happening are a couple of those duties that a careful medical caretaker consistently needs to remember. As indicated by Anthony Lee (2007), regardless of whether it is stomach medical procedure, plastic medical procedure, or some other obtrusive careful treatment, it is perilous to expect 100% security. He additionally focused on that because of the supernatural occurrences that medical procedure gives, individuals may regularly will in general overlook the dangers and complexities that go with it. One of these dangers ordinarily connected with medical procedure is the event of profound vein apoplexy in the postoperative stage. Without thromboprophylaxis, profound vein apoplexy (DVT) is a noteworthy hazard for careful patients particularly those experiencing orthopedic medical procedure and extensive strategies (ICS 2002, SIGN 2002, Geerts et al 2004, ICS 2006, NICE 2007). This reality gave me the enthusiasm of picking DVT anticipation as my theme for the introduction in order to make me and the audience members increasingly proficient about DVT hazard appraisal counteraction subsequently annihilating this entanglement from happening. This exposition calls attention to a reflection about the 15-minute class introduction that I finished inside the course of my examination. Using the Gibbs (1988) intelligent model, I would be sharing my learning and emotions dependent in general understanding. Depiction During the primary gathering with our program mentors, we were orientated to set up a 15-minute introduction of any theme identified with our entire adjustment experience which would especially concentrate on proof based practice. This would survey not just our insight and dominance of the picked theme yet it would likewise evaluate our correspondence and presentational abilities. In view of the task given, I made an exploration about proof based practice to direct me in picking my theme. As refered to by Sackett, et al (1996), proof based practice is the scrupulous, unequivocal and wise utilization of current best proof in settling on choices about the consideration of individual patients. The act of proof based medication implies incorporating individual clinical ability with the best accessible outer clinical proof from methodical examination. In light of these discoveries, I continued with my journey for an intriguing topic.ã‚â Inside the week, I had the option to deal with a patient who was conceded for suspected profound vein apoplexy

Kjlk free essay sample

If you don't mind don't hesitate to utilize extra sources to enhance your assignments. All through the semester, you will be urged to talk about any present business news with the class, particularly on the Discussion Board. It is essential to be educated of the present outside condition and how your association is influenced. Index Description Process and task the executives and improvement of utilitarian methodologies to make an incentive for a business and their customers; the board apparatuses and approaches for breaking down activities and applications to a wide assortment of administrative decisions.Credit: Three hours. Course Learning Outcomes and Objectives Learns Eng Objectives: To assist understudies with understanding their associations in todays changing operational condition. *To help understudies to decide how to turn out to be progressively viable experts in their condition. * To support understudies certainty as they direct and adapt to the complexities of progress. Learns Eng Outcomes: * Students will have the option to basically think about the obstructions and open doors for effective authoritative change. We will compose a custom exposition test on Kjlk or then again any comparative point explicitly for you Don't WasteYour Time Recruit WRITER Just 13.90/page Understudies will show successful correspondence while examining operational results. * Students can clarify the effect of arrangement for association missions and operational arranging. Understudies can talk about the advancement of administration and the significance of both the inner and outside client. * Students can know about the significance of nonstop improvement in the activities of their associations. Incapacity Us port Policy Statement: Texas Womans University tries to give fitting scholarly acclimations to all people with disabilities.This University will conform to all relevant government, state, and neighborhood laws, guidelines, and rules, explicitly Section 504 of the Rehabilitation Act of 1 973, and the Americans with Disabilities Act (DAD), concerning giving proper scholastic changes in accordance with bear the cost of equivalent instructive chance. It is the obligation of the understudy to enroll with and give clinical check and scholarly timetables to Disability Support Services (ADS) toward the start of every semester and no later than the second seven day stretch of school except if in any case controlled by the coordinator.The understudy likewise should contact the employee in an opportune way to mastermind fitting scholastic alterations. For additional data with respect to Disability Support Services or to enroll for help, if it's not too much trouble contact the workplace at 898-3835 (voice), 898-3830 (ADD) or Visit 105. Scholarly Dishonesty strategy: Academic uprightness is the establishment of the scholastic network. Since every understudy has the essential obligation regarding being scholastically fair, understudies are liable for perusing and seeing all segments in the Student Handbook (p. 3-55) identifying with guidelines of lead and scholastic life. Scholastic deceptive nature incorporates cheating, unoriginality, intrigue, manufacture, adulteration, and misrepresenting scholarly records, and different acts deliberately intended to give unjustifiable bit of leeway to the understudy, or potentially the endeavor to submit such acts. Understudies who disregard college runs on scholarly snootiest are dependent upon disciplinary punishments, including the chance of disappointment or expulsion from a course, discipl inary probation, and additionally excusal from the University. See subtleties in the accompanying URL: http://www. Two. Du/o-SSL/Stultification/sedimentations. HTML Other assets identifying with scholastic trustworthiness and Plagiarism: 1. The Library has another video instructional exercise on copyright infringement. On the librarys landing page (http://www. Television. Due/library/)- (on the right), or all the more explicitly http://www. Two. Due/library/instructional exercise/written falsification/player. HTML 2. The Library likewise has a pleasant Powering introduction on a similar subject http://www. Two. Due/as/inundates/shared/apparatuses/copyright infringement. PPTP). Assignments General data: All assignments are expected at 1 :pm on the due date. Late assignments won't be accepted.If you experience a circumstance where you won't have the option to finish a task on schedule, if it's not too much trouble let us know as quickly as time permits. On the off chance that we don't get notification from you, we will expect that you decided not to finish the task and will get a score of zero. The Case Studies and the Book Assignment are printed for reviewing and should be submitted as appended word records by means of the connection under the individual task (Note: click on the task name) and might be submitted preceding their due dates. You may utilize extra sources to enhance your assignments.You may be permitted one endeavor while presenting your assignments through Blackboard, so please audit your assignments cautiously before submitting. As an understudy in this course, it is your duty to present the right and finished task. Try not to send extra entries to the email we have constrained email space and the inbox can get over-burden. In the event that we can't open your assignments, you will be reached by means of email. Task organizing: Assignments must be composed in 12 point textual style (Times New Roman), utilizing 1 inch margins.Please incorporate your name, class number, segment number, and the task number on each page in a header. In the event that you don't give this data on your archive, 10 focuses will be deducted from your task grade. Conversation Board Questions: Answers to Discussion Board questions are expected at 1 :pm on the due date. Questions can be found under the Discussions tab on Blackboard. Notwithstanding your unique reactions, answer to in any event 2-3 understudy posts for each question by the Forums due date. If it's not too much trouble make a point to give separate sections to each post you submit.Case Studies: Five (5) Case Studies will be expected all through this course. It would be ideal if you complete the inquiries for the five Case Studies; they can be found toward the finish of the parts in your MOM eBook. Contextual investigations have arrived at the midpoint of between 2-3 pages long. Book Assignment: Your Book Assignment will be over the book Good to Great by Jim Collins; you should buy this book. To increase a more profound comprehension of the key ideas saved in the book, plan composed reactions to any four (4) of the six (6) questions recorded underneath. For every reaction be attentive and concise yet not superficial.This is a huge task and ought to have thought, application, and mirror that you have undoubtedly perused the book. Book assignments have arrived at the midpoint of between 5-7 pages long. 1. 0 Level 5 Leadership Which is more diligently to develop inside yourself: modesty or will? 2. 0 Who First? On the off chance that remuneration isn't the essential driver for the opportune individuals on the transport, at that point what are the essential components in getting and keeping the perfect individuals on the transport? What job does remuneration play? 3. 0 Confront the Brutal Facts Do you have any warning systems throughout your life or association? What thoughts do you have for new ones? 4. 0 Hedgehog ConceptWhich is increasingly significant for an association, the objective to be the best at something, or reasonable comprehension of what you can (and can't) be the best at 5. 0 Culture Of Discipline Think oft individuals: One being somebody who just considers his to be her activity as a vocation and the other who comprehends that the person has an obligation. How does the distinction run its course in their work? In their own life? What would it be advisable for us to search for in finding such individuals? 6. 0 Technology Accelerators Why is there so much promotion and dread about new innovations, and what would you be able to do to see new advances with target poise?

Paper Writing Service - How to Get the Best Paper Writing Service For the Price You Can Afford

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The Simple Pleasures of Life Bring Happiness Essay

I am determined to be cheerful and happy in whatever situation I may find myself. For I have learned that the greater part of our misery or unhappiness is determined not by our circumstance but by our disposition. -- Martha Washington Happiness is not something ready made. It comes from your own actions. -- Dalai Lama An emotion is an intense feeling. Happiness is one of the many emotions humans experience. It may perhaps be the most important feeling a person can have and it is the one feeling everyone strives to achieve, yet strangely, for the most part, people seem to only get a glimpse of it. Pleasurable satisfaction, a state of well-being and contentment are the more outstanding elements of happiness. Happiness, known†¦show more content†¦Happiness is denoted by the way a person behaves. Usually when someone is happy it is obvious and they express this feeling outwardly, whether by their actions or verbally. The facial area is the main part through which happiness is shown. The expressions of the face such as a twinkle in the eyes when joyous, the ever-present laugh lines around the eyes, which constantly smile at you, makes the on-looker aware of a happy person. The mouth plays an important role in showing that a person is content, through both physical and verbal means. The ra diant smiles with the accompanying dimple, spreads delight and pleasure. Laughter, a universal expression of joy, travels through the air spreading cheer to all that hear it. Other verbal expressions of gaiety take the form of song singing, which has always been used over the years to express feelings of happiness, and exuberant chatter, which infuses the air with excitement and enthusiasm. Physical expressions of joy are not limited to the facial area alone. Extending to the whole body, happiness is shown through skipping, the swinging of hands, twirling, dancing and almost any rhythmic movement of the limbs. Children show their happiness, mostly but not solely, by running, jumping, skipping and sometimes rolling on the ground. Adults are for the most part less energetic with their expressions of joy, and show their joy by twirling and dancing, mostly females, and by punching the air. It is not necessary however, for aShow MoreRelatedHedonism, By Robert Nozick1272 Words   |  6 PagesInsufficient for Well-Being Hedonism is the belief that pleasure is the most important thing in life and everything else is trivial as long as you are getting pleasure, the goal being to accumulate the greatest amount of net pleasure in ones lifetime. I disagree with the thought that hedonism is the correct view of well-being for people. Life is more than breaking down acts into something as simple as level of pleasure and then determining happiness off of that. By examining Nozick’s experience machineRead MoreAristotle Vs. 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Through the explanation of pleasure as we ll as its arguable counterpart, suffering and the discussion of their values in addition to the counterargument of hedonic treadmill, Kupperman’s views about the role of pleasure in living a good life can be strongly supported and evaluatedRead MoreAristippus : The Philosophy Of Socrates1147 Words   |  5 Pages He was a pupil of Socrates, and became close to Socrates even though his philosophical views differed. Aristippus believed the goal of life and living revolved around pleasure, seeking pleasure no matter what the circumstance is. Aristippus believed having pleasure meant having happiness, and ones happiness revolved around everything else. Ultimately, pleasure was the true motive of living. Aristippus was the founder of the Cyreneic school of Philosophy. At this school, Aristippus taught about

Rhetorical Analysis Of The Lucifer Effect - 846 Words

Rhetorical Analysis: The Lucifer Effect The Lucifer Effect examines how the human mind has the capacity to be infinitely caring or selfish, kind or cruel, creative or destructive. This work analyses the Stanford Prison Experiment, and the author’s personal experiences as an expert witness for one of the Abu Ghraib prison guards, to raise fundamental questions about the nature of good and evil. Mankind wants us to believe that there is a little good in all of us. Zimbardo created a min blowing experiment that examine the human mind. The Stanford prison experiment was a study of the psychological effects of becoming a prisoner or prison guard. The experiment was conducted at Stanford University on August 14–20, 1971, by a team of researchers led by psychology professor Philip Zimbardo. It was funded by the U.S. Office of Naval Research and was of interest to both the U.S. Navy and Marine Corps as an investigation into the causes of conflict between military guards and prisoners. The experiment is a classic stud y on the psychology of imprisonment and is a topic covered in most introductory psychology textbooks. The participants adapted to their roles well beyond Zimbardo s expectations, as the guards enforced the measures and ultimately subjected some of the prisoners to psychological torture. Many of the prisoners passively accepted psychological abuse and, at the request of the guards, readily harassed other prisoners who attempted to prevent it. The experiment evenShow MoreRelatedThe Lamb and The Tyger by William Blake Essay1758 Words   |  8 Pageslights. â€Å"The Tyger,† written in 1774, and â€Å"The Lamb,† written five years later in 1789, are considered companion poems due to their similar humanistic topic and stark differences of each other. Through the use of specific titillation and use of rhetorical questioning, Blake sets up an ultimatum between the two poems, creating the illusion that each creature in the poems may have different creators. In this way, Blake questions traditional Christian doctrine in such a way that initiates curiosityRead MoreThe Movement t hat Revolutionized the Civil Rights: Black Panthers1333 Words   |  6 Pagesactivists they became national heroes to black people everywhere. After experiencing police brutality themselves, Bobby and Huey felt obligated to assemble an organization to deal with the injustice. A poem titled â€Å"Uncle Sammy called me fulla’ Lucifer†, written Huey made many people stop and listen to Huey and Bobby’s philosophy, thus the creation of the Soul Students Advisory which was the beginning of the movement. (USPoliticsonline.net) Many people were eager to find a leader in the 1960s who

Reflections On The Nature And Study Of Buddhism - 1676 Words

Aptly titled â€Å"Reflections on the Nature and Study of Buddhism†, chapter fourteen of Buddhism—The Ebook, by Charles S. Prebish and Damien Keown does exactly that. This part of the text explains Buddhism’s spread to western civilization and how Americans altered it, its evolution into an academic discipline in America, and the role of technology in the discipline of Buddhist Studies. On page 288 of the text, writer Stephen Batchelor describes the western hemisphere’s first encounter with Buddhism as an â€Å"Awakening of the West.† This so called â€Å"awakening† was not an instantaneous or widespread hit, but factors like Buddhist influences in the arts and a â€Å"steadily increasing number of converts and Buddhist institutions† prove that Buddhism was†¦show more content†¦There is no written documentation of the development of Buddhist Studies in America as an academic discipline; from the little that is known, it seems appropriate to attribute the beginning of Buddhist Studies to the aforementioned Paul Carus, along with Henry Clarke Warren and Charles Rockwell Lanman. The first two founding fathers, Henry Clarke Warren and Charles Rockwell Lanman, both studied Sanskrit and taught scholars how to interpret the language. 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Autism and Evidence-based Practice free essay sample

This document represents a remarkable collaboration by a diverse group of stakeholders all committed to a single goal – improving the lives of children and youth with Autism Spectrum Disorders. The vision and support of the Maine Department of Education and the Maine Department of Health and Human Services enabled this work to be done, while Lindsey Tweed and Nancy Connolly provided the leadership that kept the project moving forward. We received invaluable input and guidance from a variety of viewpoints, including people with autism, parents, educators, providers, researchers, and policymakers. This was a challenging task requiring countless hours of article review and discussion over a one-year period. Although opinions differed at times, enthusiasm for the project never waned, and consensus was achieved. Throughout this involved process, the focus was always on the children and families impacted by Autism Spectrum Disorders. We are grateful to the consumers and families who shared their stories, experiences, and opinions, and who gave meaning to our work. The members of the Committee collaboratively developed a common understanding of research and evidence-based practice, selected interventions to evaluate, and outlined a literature review and rating process. The Committee collectively endorses the findings and conclusions expressed herein. However, due to the diversity of perspectives and experiences within the Committee, the conclusions and thoughts on each position in this document do not necessarily represent the individual opinions of each member or the organization they represent. Page 5 CHILDREN? S SERVICES EVIDENCE-BASED PRACTICE ADVISORY COMMITTEE MEMBERS OF THE AUTISM SPECTRUM DISORDERS PROJECT Nancy Connolly (Co-Chair) Special Education Consultant Department of Education Lindsey Tweed (Co-Chair) Director of Clinical Policy and Practice Children? s Behavioral Health Services Department of Health and Human Services Amy Beaulieu (Staff) Policy Associate, Cutler Institute Muskie School of Public Service University of Southern Maine Amy Benham Special Education Teacher, Autism Program Winslow Elementary School Sharon Brady Director of Special Services Riverside RSU #26 Betty Carolin Clinical Coordinator Charlotte White Center Janine Collins Consumer Advocate Research Associate University of Maine Center for Community Inclusion Disability Studies Nancy Cronin PDD Systems Change Coordinator Maine Developmental Disabilities Council Cathy Dionne Parent Co-Director Autism Society of Maine Page 6 Cynthia Dodge Director of Clinical Services Spurwink Services Roxy Hennings Director of Continuous Quality Improvement Division of Juvenile Services Department of Corrections Alan Kurtz Research Associate University of Maine Center for Community Inclusion Disability Studies James Pelletier Program Manager Department of Health and Human Services Division of Child Welfare Lora Perry Parent Executive Director of ABA Services Providence of Maine Matthew Siegel Medical Director Developmental Disabilities Program Spring Harbor Hospital Maine Medical Center Lynn Silva Assistant Director of Student Support Services Portland Public Schools Erica Thompson Special Services Administrator, MSAD # 54 Distinguished Educator Child Development Services Interventions for Autism Spectrum Disorders STATE OF THE EVIDENCE EXECUTIVE SUMMARY| Introduction| The number of children in Maine with Autism Spectrum Disorders (ASD) has increased significantly over the past decade. Since 2000, the number of children receiving Special Education services for ASD in Maine schools jumped from 594 to 2,231in 2008 – an increase of 276%. A recent study estimated that the total cost of caring for a person with autism over his or her lifetime can reach $3. 2 million, with more than $35 billion spent collectively per year (Ganz, 2007). To conserve already scarce resources and offer the best possible services to children with ASD, it is necessary to identify and understand the treatments and methods that produce positive outcomes as proven by research. Science helps to clarify some of the confusion about what â€Å"works† and enables evidence-informed treatment decisions, thus saving precious time and resources. Autism Spectrum Disorders are a category of neurodevelopmental disorders characterized by distinct and pervasive impairment in multiple developmental areas, particularly social skills and communication (American Psychological Association, 2000). Children with ASD exhibit atypical patterns of social interaction and communication that are not consistent with their developmental age. These patterns become apparent in the first few years of life and are generally lifelong challenges (Schieve, Rice, Boyle, Visser, Blumberg, 2006). Early, intensive identification and intervention can greatly improve outcomes for children with ASD (Eikeseth, Smith, Jahr, Eldevik, 2007). Early and effective treatment also offers opportunity for significant cost/benefit improvement through regained productivity of individuals with ASD and their caregivers (Ganz, 2007). Evidence-Based Practice| Evidence-based practice is a framework for integrating what is known from research into real-world settings in a manner that responds to the individual characteristics and values of the individual being served. There are three main components to evidence-based practice (APA Presidential Task Force on EvidenceBased Practice, 2006; Burns Hoagwood, 2002): Best Research Evidence: In order to integrate research into practice, it is critical to be aware of the scope and quality of the literature. The quality and type of research is an important factor in the evaluation of evidence. Efficacy, the extent to which the treatment had the desired effect on the outcomes, is the critical determinant of empirical evidence (Chorpita, 2003). Clinical Expertise Judgment: Practitioners in an evidence-informed framework exercise their clinical judgment to select methods that address the client? s needs by taking into account the client? s Page 7 environment, life circumstances, strengths, and challenges (APA Presidential Task Force on Evidence-Based Practice, 2006). Values: Evidence-based practice is consistent with the child and family? s values and perspectives (APA Presidential Task Force on Evidence-Based Practice, 2006; Chambless Hollon, 1998; Chorpita, 2003). Engaging families in the process of evaluating, identifying, and implementing evidence-based interventions is critical. Family engagement promotes collaboration between families and practitioners and better informs individual treatment planning. This project focused on the first factor in evidence-based practice – best research evidence. The purpose of this work was twofold: Systematically review the research literature for treatment in ASD and subsequently determine the levels of empirical evidence for treatments commonly used for children with ASD. It is hoped that addressing this first element of evidence-based practice will enable providers, families, and systems to use the latest research to better inform treatment planning, decision making, policy making, and resource development. Process| In response to a growing need for information on evidence-based treatments for ASD, the Maine Department of Education and the Maine Department of Health and Human Services led a partnership of stakeholders in a systematic review of the latest research on treatment for ASD. This review was designed as an update to the Maine Administrators of Services for Children with Disabilities (MADSEC) Autism Task Force Report issued in 2000, one of the first efforts in Maine to review the treatment literature for ASD. Over the course of a year, laypersons, state agency staff, providers, and researchers, reviewed more than 150 studies of 43 different treatments for children with ASD. The Committee objectively reviewed the research using a validated rubric, the Evaluative Method for Determining Evidence-Based Practice in Autism (Reichow, Volkmar, Cicchetti, 2008), and assigned each intervention a level of evidence rating. The quality of each study was carefully evaluated using a set of primary and secondary quality indicators and factored into the determination of the level of evidence using a corresponding rating scale. Levels of Evidence| Established Evidence: The treatment has been proven effective in multiple strong or adequately rated group experimental design studies, single-subject studies, or a combination. Results must be replicated in studies conducted by different research teams. Promising Evidence: The intervention has been shown effective in more than two strong or adequately rated group experimental design studies or at least three single-subject studies. Additional research is needed by separate teams to confirm that the intervention is effective in across settings and researchers. Preliminary Evidence: The intervention has been shown effective in at least one strong or adequately rated group or single-subject design study. More research is needed to confirm results. Page 8 Studied and No Evidence of Effect: Numerous (three or more) strong or adequately rated studies have determined that the intervention has no positive effect on the desired outcomes. Insufficient Evidence: Conclusions cannot be drawn on the efficacy of the intervention due to a lack of quality research and/or mixed outcomes across several studies. Evidence of Harm: Studies or published case reports indicate that the intervention involves significant harm or risk of harm, including injury and death. Findings| Level of Evidence Intervention Category Intervention(s) Established Evidence Applied Behavior Analysis Applied Behavior Analysis for Challenging Behavior Applied Behavior Analysis for Communication Applied Behavior Analysis for Social Skills Early Intensive Behavioral Intervention (EIBI) Augmentative and Communication Picture Exchange Communication System (PECS) Alternative Pharmacological Approaches Applied Behavior Analysis Applied Behavior Analysis for Adaptive Living Skills Augmentative and Communication Promising Evidence Halperidol (Haldol) – Effective for aggression Methylphenidate (Ritalin) – Effective for hyperactivity Risperidone (Risperidol) – Effective for irritability, social withdrawal, hyperactivity, and stereotypy Voice Output Communication Aid (VOCA) Alternative Psychotherapy Preliminary Evidence Cognitive-Behavioral Therapy (CBT) for Anxiety Applied Behavior Analysis Applied Behavior Analysis for Academics – Numeral recognition, reading instruction, grammatical morphemes, spelling. Applied Behavior Analysis for Vocational Skills Augmentative and Communication Sign Language Alternative Developmental, Social-Pragmatic Models Developmental, Social-Pragmatic Models Eclectic Models Diet Nutritional Approaches Vitamin C – Modest effect on sensorimotor symptoms only Pharmacological Approaches Atomoxetine (Strattera) – Effective for attention deficit and hyperactivity Clomipramine (Anafranil) – Effective for stereotypy, ritualistic behavior, social behavior Page 9 Level of Evidence Intervention Category Intervention(s) Clonidine (Catapres) Effective for hyperactivity, irritability, inappropriate speech, stereotypy, and oppositional behavior Psychotherapy CBT for Anger Management Sensory Integration Therapy Touch Therapy/Massage Other Hyperbaric Oxygen Treatment Studied and No Evidence of Effect Pharmacological Approaches DMG Secretin Insufficient Evidence Applied Behavior Analysis Applied Behavior Analysis for Academics – Cooperative learning groups Augmentative and Communication Facilitated Communication Alternative Diet Nutritional Approaches Developmental, Social Pragmatic Models Guanfacine (Tenex) Intravenous Immunoglobin Melatonin Naltrexone (Revia) SSRIs: Citalopram (Celexa), Fluoxetine (Prozac) Valproic Acid (Depakote) Sensory Integration Therapy Auditory Integration Training Sensory Integration Training Social Skills Training Social Skills Training Social Storiesâ„ ¢ Other Page 10 DIR/Floortime RDI SCERTS Solomon? s PLAY model Pharmacological Approaches Evidence of Harm Gluten-Casein Free Diets Omega-3 Fatty Acid Supplements Vitamin B6/Magnesium Supplements TEACCH Pharmacological Approaches Intravenous Chelation Using Edetate Disodium Conclusions| Based on its investigation of the research literature, the Committee concludes the following: The research clearly indicates that there are effective treatments for some core deficits and related challenges of ASD. For instance, comprehensive behavioral treatment has some of the most compelling evidence which emphasizes the importance of early and intensive intervention for children with ASD. Substantial investment in quality research is needed to further define effective treatment for ASD. Research specific to educational and behavioral interventions for children with ASD in the context of schools is seriously lacking. This is of deep concern since children receive a great deal of services through the education system. Comparative research on the efficacy of various treatment models would be very valuable. There is a dearth of research on treatment of older youth, adolescents, and adults with ASD. This is worrisome given that the number of adults with ASD is expected to significantly increase in the coming years as children with ASD mature. Families should be informed consumers of treatment and ask questions of providers about the nature and quality of the research behind the treatment their child is receiving. Providers need to make treatment decisions in active partnership with families while integrating relevant research into their practice and treatment planning process. Resources are needed to build capacity throughout Maine in order to efficiently and effectively deliver evidence-based treatments to children in their schools, homes, and communities. This requires resources for training, evaluation, and workforce development. For example, ABA has some of the best evidence for treatment in ASD yet Maine has only 26 certified ABA practitioners, with most located in the southern counties. Evidence-based practice does not seek to dictate the interventions that should be used at the expense of others. Rather, it is a framework to integrate what is known from research into real-world practice in a manner that is accessible to families, responsive to what children need, and consistent with what providers can accomplish given available skills and resources. The first step toward evidence-based practice is creating awareness of what the best available research says. It is no longer enough to use what we believe works, we must consider what we know works in order to close the gap between science and practice, utilize limited resources wisely, and best serve Maine children with ASD. Page 11 Interventions for Autism Spectrum Disorders STATE OF THE EVIDENCE INTRODUCTION| Recent statistics indicate that the number of children diagnosed with Autism Spectrum Disorder (ASD) has skyrocketed – the latest figures suggest that approximately 1 in 91 children in the United States are currently diagnosed with ASD (Kogen, Blumberg, Schieve, Boyle, Perrin, Ghandour, et al. , 2009). In Maine, the rate is thought to be even higher with an estimated 1 in 77 children identified with ASD – the second highest rate in the nation (Thoughtful House Center for Children, 2009). In response to increasing demand for services for children with ASD in our schools and communities, the Maine Departments of Education and Health and Human Services partnered with members of the community to assess the research and determine the level of scientific evidence for interventions currently available for ASD. This project continued the efforts of the Children? s Services Evidence-Based Practice Advisory Committee (â€Å"the Committee†) to study and disseminate information on the scientific evidence for treatments of childhood behavioral health conditions. This work also serves as a comprehensive update to the Autism Task Force Report issued in 2000 by the Maine Administrators of Services for Children with Disabilities (MADSEC). To the best of the Committee? s knowledge, the MADSEC report was the first multidisciplinary effort in Maine to objectively examine the research for select interventions for ASD. In the years since MADSEC issued its report, the breadth and depth of the research of ASD has evolved; in fact, more than 2,100 studies regarding autism have been published in peer-reviewed journals since 2001i. Given the significant number of children with ASD being served in Maine and advances in research over the last decade, a new review of the literature is timely and appropriate. The Committee evaluated peer-reviewed research for more than 40 interventions for children and youth with ASD, including psychosocial, behavioral, developmental, complementary, educational, and pharmaceutical treatments. A wide variety of treatment options have been developed for children with ASD and it can be difficult for parents, educators, and practitioners to know what could be most effective given each child? s unique circumstances. Science helps to clarify some of the confusion about what â€Å"works. † Well-designed studies can show that some interventions are very effective for certain symptoms or behaviors while others are not. The implications of this information are profound; understanding what works as demonstrated by research can inform choices that improve lives (Steele, Roberts, Elkin, 2008). Page 12 How to Use This Report| This document is intended to provide an updated view of the best available research evidence for treatments for Autism Spectrum Disorders. Certain stakeholders may find this report especially useful: Families, Educators, Practitioners: Evaluating and selecting treatments can be a daunting task. This report provides an objective evaluation of the best available research evidence for the myriad of treatment options currently available for ASD (Steele, et al. , 2008). Policymakers: As Maine continues to enhance its system of care, it is hoped that policymakers will consider this information in their decision making so that all children in Maine have sufficient access to evidence-based interventions. Business Community Leaders: ASD touches the lives of many families in the places where we live and work. The Committee hopes that sharing information on effective treatment methods inspires leadership, innovation, and support among business and community leaders to improve service delivery systems. Researchers: Describing the amount and quality of research behind available treatments draws attention to areas needing further research and investigation. Children with ASD truly have a spectrum of challenges and abilities therefore treatments should be tailored to reflect their individuality. It is not enough to simply use any evidencebased treatment they are not â€Å"one size fits all. † The treatments discussed in this report vary widely in their focus, intensity, duration, and methods, and thus must be carefully evaluated and matched to a child? s unique needs. It is not the intention of this report to indicate what interventions should or should not be used; families should always decide what treatment best meets the needs of their child. Children have a right to treatment that is reflective of their individual strengths and challenges and that accommodates any change in the nature and intensity of their needs (Office of Child and Family Services, March 2008). However, families and providers should seek the most current and complete research information to factor into their decisions regarding treatment. As â€Å"Treatment† â€Å"Intervention† Treatment is generally understood as a service used to correct or alleviate a specific medical condition, issue, or problem. The effectiveness of treatment is usually evaluated and measured based on the individual? s outcome (Barker, 1999). Intervention includes treatment, but also encompasses other services or activities practitioners use to address or prevent an individual? s problems (Barker, 1999). Intervention is a term sometimes used in social work, education, and other ecological, cross-disciplinary fields to describe services that address the problems of an individual. The Committee reviewed â€Å"treatments† and â€Å"interventions† without regard to the field or entity that might utilize them. These terms are used interchangeably in this report. Page 13 science continues to evolve, it is expected that ASD treatment will be further refined. Therefore, periodic reassessments of the scientific literature will be needed so that families and providers have current information in order to inform their choices and decisions. PROJECT ORGANIZATION| The Children? s Services Evidence-Based Practice Advisory Committee formed in 2007 as the childfocused Subcommittee of the DHHS EvidenceBased Practice Advisory Committee. The Committee is charged with reviewing the research base for treatments of childhood behavioral health disorders in order to better inform policy, practice, and resource development in Maine. It is not a policy-making entity, but an advisory body that informs state agency work. The Committee is led by Children? s Behavioral Health Services, a division of the Office of Child and Family Services. Departnent of Education DHHS EvidenceBased Practice Advisory Committee Childrens Services Evidence-Based Practice Advisory Committee Autism Spectrum Disorders Project FIGURE 1: PROJECT ORGANIZATION A diverse group of stakeholders convened in 2007 to review and rate the research on psychosocial treatments for disruptive behavior disorders (Beaulieu, 2008). Following this successful review, the Committee turned its attention to ASD due to a growing concern about the needs of this population. The Maine Departments of Education and Health and Human Services agreed to jointly lead this project in recognition of the mutually important roles that education and behavioral health systems play in serving children with ASD. The Muskie School of Public Service provided technical assistance, research support, and data analysis to the project through a cooperative agreement with the Office of Child and Family Services. Due to the nuances involved in ASD research and the relevance of this issue across systems, the Committee incorporated stakeholders and experts in the field of ASD, including parents, an adult with ASD, educators, providers, and advocates. The Autism Spectrum Disorders project began in August of 2008. Initial work focused on establishing common language and understanding about ASD, research methodology, and evidence-based practice. Following a review of the literature, the Committee adopted a systematic review process with a corresponding rating scale to organize the work. ABOUT AUTISM SPECTRUM DISORDERS| Definition| Autism Spectrum Disorders, also referred to as Pervasive Developmental Disorders (PDD), are a category of neurodevelopmental disorders that include: Page 14 Autistic Disorder (autism); Pervasive Developmental Disorders-Not Otherwise Specified (PDD-NOS); Asperger? s Syndrome; Rett? s Disorder; and Childhood Disintegrative Disorder. ? ? ? Autism Spectrum Disorders are now more common than childhood cancers in the United States. (Gloeker, Percy, Bunin, 2005) Due to their lower prevalence and differing symptom profile, Childhood Disintegrative Disorder and Rett? s Disorder were not included ? ? ? in this review. Research of treatments for ASD generally does not include children with these two diagnoses. Studies that focused on children with Autistic Disorder, PDD-NOS, and/or Asperger? s Syndrome were reviewed. Because functional ability and expression of symptoms can vary widely among children with these diagnoses, from profound disability to high functioning, they are said to exist on a â€Å"spectrum. † The Committee chose to use the term â€Å"Autism Spectrum Disorders† rather than Autism or PDD in recognition that no two children are impacted by these disorders in exactly the same manner or to the same degree. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Autism Spectrum Disorders (ASD) are characterized by distinct and pervasive impairment in multiple developmental areas, primarily social skills and communication (American Psychiatric Association, 2000). These disorders are marked by the presence of stereotypical behavior such as hand flapping and body rocking, as well as by excessive preoccupation with certain objects, interests, or activities. Children with ASD exhibit patterns of social interaction and communication that are not consistent with their developmental age. These patterns become apparent in the first few years of life and are generally lifelong challenges (Schieve, Rice, Boyle, Visser, Blumberg, 2006), although with early and effective intervention, children can often learn new skills and improve existing ones. Prevalence| Studies have consistently documented a significant increase in the number of children identified with ASD across the United States over the last 15 years (Centers for Disease Control and Prevention, Maine Children Classified with Autism in 2009; Hollenbeck, 2004; Schieve, et al. , 2006). Special Education 2000-2008 While it is not known if this increase is attributa2231 ble to how ASD is identified and diagnosed, an 276% 1760 2500 2000-2008 actual increase in prevalence, or a combination 2000 of factors, the number of children identified with 1500 594 ASD in Maine and across the country has been 1000 500 growing. ASDs are now the second most common 0 developmental disability after mental retarda2000-01 2006-07 2008 tion (Centers for Disease Control and Prevention, 2009). A recent national survey of parents by Source: Department of Education, 2009 Page 15 U. S. Department of Health Human Services estimated that 1 in 91 children ages 3-17 years old were currently diagnosed with ASD (Kogen, et al. , 2009). This is a substantial increase from earlier estimates by the Centers for Disease trol of 1 in 150 children (Centers for Disease Control and Prevention, 2009). MaineCare Recicipients with ASD 2000-2008 3000 281% 2000-2008 1929 2451 2000 1000 643 0 Prevalence in Education| 2000 2006 2008 Education data echo this trend. Federal data Source: Department of Health and Human Services, gathered for the Individuals with Disabilities in 2009 Education Act (IDEA) indicate that the number of Maine children ages 6-22 with ASD receiving Special Education services grew by 1672% between 1992 and 2003 (Hollenbeck, 2004). This is pared to a nationwide 834% increase in children ages 6-17 with ASD between 1994 2006 (Centers for Disease Control and Prevention, 2009). Maine Department of Education data shows this trend is likely to continue. Since 2000, the number of children in Maine schools classified with ASD has increased by 276% (Department of Education, 2009). Prevalence among Medicaid Recipients| Utilization data from the Medicaid program also shows an increase in the prevalence of ASD in Maine. Between 2000 and 2008, the number of people with ASD who received MaineCare services increased by 281%. The significant growth of ASD in Maine? s systems of care underscores the need for planful resource and capacity development in order to adequately address the needs of this expanding population (Department of Health and Human Services, February 2009). WHAT IS EVIDENCE-BASED PRACTICE? | Evidence-based practice is the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture, and preference. American Psychological Association Page 16 Evidence-based practice has been a priority in the behavioral health and education fields over the past decade. The growing need for high-quality children? s behavioral health services has increased the demand for treatments that are proven to produce better outcomes (Levant, 2005; New Freedom Commission on Mental Health, 2003). The education system has also emphasized the use of evidence-based practice through legislation and policy such as No Child Left Behind (Coalition for EvidenceBased Policy, December 2003). For example, federal education policy calls for educators to address the needs of students struggling with academics and behavior with interventions supported by research (Gresham, 2007). The emphasis on inter- Control condition: A comparison group of subjects in a research study that receive treatment as usual, or are placed on a waiting list for the treatment under study. Efficacy: The strength of the causal relationship between the treatment and its intended outcomes Does it work? Effectiveness: An assessment of how well the treatment generalizes to real-world settings. Randomized Controlled Trial: A type of research study in which subjects are randomly selected to receive the experimental intervention or a control condition. Single-Subject Design: A type of research that measures effects of an intervention at the level of the individual under carefully controlled conditions. ventions backed by research necessitates a common derstanding of evidence-based practice. Defining and coming to a common understanding of â€Å"evidence† is not simple (Chambless Hollon, 1998; Chorpita, 2003). Our current understanding of evidencebased practice in behavioral healthcare is largely rooted in the work of American Psychological Association Task Forces (Task Force on Promotion and Dissemination of Psychological Procedures, 1995; Task Force on Psychological Intervention Guidelines of the American Psychological Association, 1995). These Task Forces developed some of the first guidelines on research-informed practice (Chambless, et al. , 1996). The Committee has endorsed the American Psychological Association? s definition of evidence-based practice: Evidence-based practice is the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture and preference (APA Presidential Task Force on Evidence-Based Practice, 2006). This definition acknowledges that evidence-based practice does not exist in a vacuum, and that research, clinical practice, and client values influence each other. Although the terms are often used interchangeably, the meanings of â€Å"evidence-based practice† and â€Å"evidencebased treatment† are distinct. Evidence-based treatment refers to specific treatments or intervention models that have proven effective for specific problems in certain circumstances by numerous scientific studies (Levant, 2005). Evidence-based practice bridges the science-to-practice gap by using research evidence to inform clinical practice in the context of the client? s needs and environment. There are three core components to evidence-based practice: Best research evidence, clinical expertise and judgment, and client values and voice (APA Presidential Task Force on Evidence-Based Practice, 2006; Burns Hoagwood, 2002). Best Research Evidence| The main element in the determination of research evidence is efficacy (Chorpita, 2003). Efficacy refers to the strength of the causal relationship between the treatment and its intended outcomes. In other words, does the treatment have the desired effect on the target behavior or skill? Efficacy is established Page 17 â€Å"Life Journey through Autism: A Parent’s Guide to Research† is an informative guide for families. through well-designed research studies in which outcomes are observed and measured and compared to a no-treatment condition. The quality and type of a research study is an important factor in the evaluation of evidence. Research studies are conducted using different methods to varying levels of scientific integrity. Available at: Well-designed research is highly controlled, meaning that the www. researchautism. org families and children are carefully screened and selected to fit the parameters of the research, and administration of the treatme