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Clinical Director, Case Western Reserve University School of Medicine
In English-language learners arrhythmia foods to eat 80 mg innopran xl sale, assessment should include con≠ sideration of whether the source of reading difficulties is a limited proficiency with Eng≠ lish or a specific learning disorder prehypertension 34 weeks pregnant buy innopran xl in united states online. Risk fac to hypertension guidelines jnc 7 purchase innopran xl 40 mg rs for specific learning disorder in English language learners include a family his to ry of specific learning disorder or language delay in the native language, as well as learning difficulties in English and failure to catch up with peers. Also, assessment should consider the linguistic and cultural context in which the individual is living, as well as his or her educational and learning his to ry in the original culture and language. Gender-Related Diagnostic issues Specific learning disorder is more common in males than in females (ratios range from about 2:1 to 3:1) and cannot be attributed to fac to rs such as ascertainment bias, definitional or measurement variation, language, race, or socioeconomic status. Functionai Consequences of Specific Learning Disorder Specific learning disorder can have negative functional consequences across the lifespan, including lower academic attainment, higher rates of high school dropout, lower rates of postsecondary education, high levels of psychological distress and poorer overall mental health, higher rates of unemployment and under-employment, and lower incomes. School dropout and co-occurring depressive symp to ms increase the risk for poor mental health outcomes, including suicidality, whereas high levels of social or emotional support predict better mental health outcomes. Specific learning disorder is distinguished from normal variations in academic attainment due to external fac to rs. Specific learning disorder differs from general learning difficulties associated with intellectual disability, because the learning difficulties occur in the presence of normal levels of intellectual functioning. If intellectual disability is present, specific learning disorder can be diagnosed only when the learning difficulties are in excess of those usually associated with the intellectual disability. Specific learning dis≠ order is distinguished from learning difficulties due to neurological or sensory disorders. Specific learning disorder is distinguished from learning problems associated with neurodegenerative cognitive disorders, because in specific learning disorder the clinical expression of specific learning difficulties occurs during the developmental period, and the difficulties do not manifest as a marked decline from a for≠ mer state. Specific learning disorder is distinguished from the academic and cognitive-processing difficulties associated with schizophrenia or psychosis, because with these disorders there is a decline (often rapid) in these functional domains. Comorbidity Specific learning disorder commonly co-occurs with neurodevelopmental. These comorbidities do not necessarily exclude the diagnosis specific learning disorder but may make testing and differential diagnosis more difficult, because each of the co≠ occurring disorders independently interferes with the execution of activities of daily liv≠ ing, including learning. Thus, clinical judgment is required to attribute such impairment to learning difficulties. If there is an indication that another diagnosis could account for the difficulties learning keys to ne academic skills described in Criterion A, specific learning disorder should not be diagnosed. The acquisition and execution of coordinated mo to r skills is substantially below that ex≠ pected given the individualís chronological age and opportunity for skill learning and use. The mo to r skills deficit in Criterion A significantly and persistently interferes with activ≠ ities of daily living appropriate to chronological age. The mo to r skills deficits are not better explained by intellectual disability (Intellectual devel≠ opmental disorder) or visual impairment and are not attributable to a neurological condi≠ tion affecting movement. Diagnostic Features the diagnosis of developmental coordinahon disorder is made by a clinical synthesis of the his to ry (developmental and medical), physical examination, school or workplace report, and individual assessment using psychometrically sound and culturally appropriate standardized tests. The manifestation of impaired skills requiring mo to r coordination (Criterion A) varies with age. They also may be delayed in de≠ veloping skills such as negotiating stairs, pedaling, but to ning shirts, completing puzzles, and using zippers. Even when the skill is achieved, movement execution may appear awkward, slow, or less precise than that of peers. Older children and adults may display slow speed or in≠ accuracy with mo to r aspects of activities such as assembling puzzles, building models, playing ball games (especially in teams), handwriting, typing, driving, or carrying out self-care sldlls. Developmental coordination disorder is diagnosed only if the impairment in mo to r skills significantly interferes with the performance of, or participation in, daily activities in family, social, school, or community life (Criterion B). Examples of such activities include getting dressed, eating meals with age-appropriate utensils and without mess, engaging in physical games with others, using specific to ols in class such as rulers and scissors, and participating in team exercise activities at school. Not only is ability to perform these ac≠ tions impaired, but also marked slowness in execution is common. Handwriting compe≠ tence is frequently affected, consequently affecting legibility and/or speed of written output and affecting academic achievement (the impact is distinguished from specific learning difficulty by the emphasis on the mo to ric component of written output skills). In adults, everyday skills in education and work, especially those in which speed and accuracy are required, are affected by coordination problems. Criterion C states that the onset of symp to ms of developmental coordination disorder must be in the early developmental period. However, developmental coordination disorder is typically not diagnosed before age 5 years because there is considerable variation in the age at acquisition of many mo to r skills or a lack of stability of measurement in early childhood. Criterion D specifies that the diagnosis of developmental coordination disorder is made if the coordination difficulties are not better explained by visual impairment or at≠ tributable to a neurological condition.
Likewise what is pulse pressure yahoo cheap innopran xl on line, Levenson blood pressure medication beta blocker discount innopran xl 40 mg mastercard, Becker and Morin (2008) emphasize the importance of understanding crossover offending patterns to blood pressure chart sleeping generic 40 mg innopran xl enhance safety planning for the offenders and the community. To address the issue of heterogeneity and crossover offending with respect to offender typologies, researchers. Recent Advances in the Development of Sexual Offense Patterns Recent models of the sexual offense process have been devised to include etiological theories of sexual offending and treatment-relevant fac to rs. Assessment, classifcation and treatment should be formulated from rehabilitation theories, which are integrative practice frameworks that contain elements of etiology, ethics and research (Ward, Yates & Willis, 2011). They are based on clusters of behaviors and psychological processes to account for the heterogeneity of offending. The heterogeneity of traits, experiences and criminal his to ry of sexual offenders requires more advanced methods of categorizing offense behaviors (Martinez-Catena et al. The most promising are the developmental pathways of sexual offending model, the self-regulation model and the specialist vs. These models take in to account problematic behaviors, dis to rted thought processes and offense his to ries. Developmental fac to rs have been shown to be predictive of high-risk sexual behaviors, treatment failure, and dynamic risk (Craissati & Beech, 2006), and the self-regulation model has been shown to be associated with static and dynamic risk for reoffense (Yates & Kings to n, 2006; Simons et al. The generalist theory of crime (Gottfredson & Hirshi, 1990) has also been examined in sexual offender research. Similar to crossover fndings, studies have shown that few sexual offenders ďspecializeĒ in sexual offending (Harris, Mazerolle & Knight, 2009; Lussier, Proulx & LeBlanc, 2005). Specialization has been associated with child sexual abusers who sexually prefer children, while rape has been associated with criminal versatility (Harris, Mazerolle & Knight, 2009). This section reviews models that may ultimately replace traditional typologies to inform treatment and management of sexual offenders. Although they are not described as typologies, they have been shown to be related to different trajec to ries of offending and they are able to identify criminogenic needs, which have been shown to be predictive of sexual recidivism (Craissati & Beech, 2006; Martinez-Catena et al. Etiological research has suggested that it is the interaction of biological and social learning fac to rs that infuences the development of sexual offending behaviors (Ward & Beech, 2008). Researchers explain that genetic fac to rs may predispose an individual to pursue a specifc human need. Negative developmental experiences fgure prominently in many models of sexual offending behavior. In a recent study of 614 incarcerated sexual offenders, childhood emotional abuse and neglect predicted sexual victimization and later sexual offending behavior (Jennings, Zgoba, Maschi & Reingle, 2014). In comparison to the general population, incarcerated sexual offenders were more than three times as likely to report sexual abuse during childhood, two times as likely to experience physical abuse, 13 times as likely to experience emotional abuse and more than four times as likely to experience neglect (Levenson, Willis & Prescott, 2016). These individuals were found to be at increased risk for substance abuse and for criminal diversity (Levenson & Socia, 2015). Indeed, a recent meta-analysis has confrmed the association between the experience of sexual abuse and subsequent sexual offending against children (Jespersen, Lalumiere & Se to, 2009). Research fndings indicate that there may not be only one type of abuse that serves as a developmental risk fac to r for later sexual offending. Instead, multiple types of abusive experiences, or a pathological family environment, may precede offending behaviors (Dube et al. Researchers have also suggested that different types of maltreatment may be associated with different types of sexual offending behaviors. This section reviews the current research fndings that compare the developmental risk fac to rs of various offender characteristics. Child Sexual Abusers Researchers have found that child sexual abusers exhibited heightened sexuality in childhood. Meta-analysis results indicate that juveniles who commit sexual offenses were more likely than nonsex offenders to have been exposed to sexual violence, sexual abuse, emotional abuse and neglect (Jespersen, Lalumiere & Se to, 2009). Within the adult sex offender population, Simons, Wurtele and Durham (2004) found that child sexual abusers, as compared to rapists, reported more experiences of child sexual abuse, early exposure to pornography, sexual activities with animals and an earlier onset of masturbation. Rapists In contrast, the childhood his to ries of rapists appear more indicative of violence. Simons, Wurtele and Durham (2004) found that rapists, when compared to child sexual abusers, reported more frequent experiences of physical abuse, parental violence, emotional abuse and cruelty to animals. Researchers contend that physical abuse, parental violence and emotional abuse result in externalizing behaviors only when they are considered in combination (Lee et al.
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Landlord reserves blood pressure 55 purchase 80 mg innopran xl overnight delivery, and shall during normal business hours upon reasonable notice to blood pressure medication bystolic side effects 40mg innopran xl visa Tenant (which may be verbal to arrhythmia types innopran xl 40mg overnight delivery Tenantís on-site manager) the right to enter the Premises, inspect the same, and to supply any service to be provided by Landlord to Tenant hereunder, to submit said Premises to prospective purchasers or during the last six months of the term to prospective tenants, to post notices of non-responsibility, and to alter, improve or repair the Premises and any portion of the Building of which the Premises are a part that Landlord may deem necessary or desirable, without abatement of Rent (so long as Tenantís access to, and use and enjoyment of, the Premises is not unreasonably interfered with) and may for that purpose in connection with any work to be performed by Landlord under this Lease. Landlord shall not be required to give any notice to Tenant in the event of any emergency, for recurring services. Landlord may erect scaffolding and other necessary structures where reasonably required by the character of the work to be performed, always providing that the business of Tenant shall not be interfered with unreasonably. Tenant hereby waives any claim for damages or for any injury or inconvenience to or interference with Tenantís business, any loss of occupancy or quiet enjoyment of the Premises, and any other loss occasioned thereby unless caused by gross negligence or willful and wan to n acts of Landlord. For each of the aforesaid purposes, Landlord shall, at all times, have and retain a key with which to unlock all of the doors in, upon and about the Premises, and Landlord shall have the right to use any and all means which Landlord may deem proper to open said doors in an emergency, in order to obtain entry to the Premises without liability to Tenant except for the gross negligence or willful and wan to n conduct of Landlord. Any entry to the Premises obtained by Landlord by any of said means, or otherwise shall not, under any circumstances, be construed or deemed to be a forcible or unlawful entry in to, or a detainer of, the Premises, or an eviction of Tenant from the Premises or any portion thereof. Tenant shall not change the locks to the Premises without Landlordís written consent. In the event the Premises, or the Building of which the Premises are a part, are damaged by fire or other perils covered by extended coverage insurance, Landlord agrees to forthwith repair the same to substantially the same condition as existed immediately prior to such damage; and this Lease shall remain in full force and effect, except that 17 Tenant shall be entitled to a proportionate reduction of the Rent while such repairs are being made, such proportionate reduction to be based upon the extent to which the damage and the making of such repairs shall materially and adversely interfere with the business carried on by Tenant in the Premises. If the damage is due to the fault or neglect of Tenant or its employees, there shall be no abatement of Rent. In the event the Premises or the Building of which the Premises are a part are damaged as a result of any cause other than the perils covered by fire and extended coverage insurance, then Landlord shall forthwith repair the same within one hundred and fifty (150) days of casualty, provided the extent of the destruction be less than ten percent (10%) of the then full replacement cost of the Premises or the Building of which the Premises are a part. In the event the destruction of the Premises or the Building is to an extent greater than ten percent (10%) of the full replacement cost, then Landlord shall have the option: (1) to repair or res to re such damage, this Lease continuing in full force and effect, but the Rent to be proportionately reduced as hereinabove in this Paragraph provided; or (2) give notice to Tenant at any time within thirty (30) days after such damage terminating this Lease as of the date specified in such notice, which date shall be no less than thirty (30) and no more than sixty (60) days after the giving of such notice. In the event of giving such notice, this Lease shall expire and all interest of Tenant in the Premises shall terminate on the date so specified in such notice and the Rent, reduced by a proportionate amount, based upon the extent, if any, to which such damage materially interfered with the business carried on by Tenant in the Premises, shall be paid up to date of said such termination. Notwithstanding anything to the contrary contained in this paragraph, Landlord shall not have any obligation whatsoever to repair, reconstruct or res to re the Premises when the damage resulting from any casualty covered under this paragraph occurs during the last twelve (12) months of the term of this Lease or any extension thereof and in the event of such casualty during the last twelve (12) months of the term of this Lease, and Landlord shall have the right to terminate this Lease by giving written notice to Tenant within thirty (30) days of such casualty. Landlord shall not be required to repair any injury or damage by fire or other cause, or to make any repairs or replacements of any panels, decoration, office fixtures, railings, floor coverings, partitions, or any other property installed in the Premises by Tenant unless covered by Landlordís insurance as part of the Building. Except as otherwise expressly authorized hereunder, Tenant shall not be entitled to any compensation or damages from Landlord for loss of the use of the whole or any part of the Premises or Tenantís personal property. The occurrence of any one or more of the following events shall constitute an Event of Default: a. The failure by Tenant to make any payment of Rent or any other payment required to be made by Tenant hereunder, within five (5) days after receipt of written notice that the same is past due. The failure by Tenant to observe or perform any of the covenants, conditions or provisions of this Lease to be observed or performed by Tenant, other than described in Paragraph 22b above, where such failure shall continue for a period of thirty (30) days after written notice thereof by Landlord to Tenant; provided, however, that if the nature of Tenantís default is such that more than thirty (30) days are reasonably required for its cure, then Tenant shall not be deemed to be in default if Tenant commences such cure within said thirty (30) day period and thereafter diligently prosecutes such cure to completion. The making by Tenant of any general assignment or general arrangement for the benefit of credi to rs; or the filing by or against Tenant of a petition to have Tenant adjudged a bankrupt, or a petition of reorganization or arrangement under any law relating to bankruptcy (unless, in the case of a petition filed against Tenant, the same is dismissed within sixty  days); or the appointment of a trustee or a receiver to take possession of substantially all of Tenantís assets located at the Premises or of Tenantís interest in this Lease, where possession is not res to red to Tenant within thirty (30) days; or the attachment, execution or other judicial seizure of substantially all of Tenantís assets located at the Premises or of Tenantís interest in this Lease, where such seizure is not discharged in thirty (30) days. If Landlord is in default in the performance of any obligation under this Lease on the part of Landlord to be performed and such default continues for a period of thirty (30) days after Tenantís written notice to Landlord specifying the nature of the default, then Tenant may exercise any right or remedy it may possess at law or equity, which is not otherwise waived in this Lease. If the default set forth in Tenantís notice cannot reasonably be cured within thirty (30) days, then Landlord shall not be deemed to be in default if (i) Landlord notifies Tenant in writing that it will cure the default, (ii) commences to cure the default within such thirty (30)-day period, and (iii) proceeds diligently and in good faith thereafter to cure such default and does cure such default within a reasonable time. In the event of any Event of Default or other breach by Tenant, Landlord may at any time thereafter, with or without notice or demand, and without limiting Landlord in the exercise of a right or remedy which Landlord may have by reason of such Event of Default or breach: a. Reenter and take possession of the Premises or any part thereof and repossess the same as of Landlordís former estate and expel Tenant and those claiming through or under Tenant and remove the effects of both or either, without being deemed guilty of any manner of trespass and without prejudice to any remedies for arrears of Rent or preceding breach of covenants or conditions. Should Landlord elect to reenter, as provided in this paragraph, or should Landlord take possession pursuant to legal proceedings or pursuant to any notice provided for by law, Landlord may, from time- to -time, without terminating this Lease, relet the Premises or any part thereof, either alone or in conjunction with other portions of the Building of which the Premises are a part, in Landlordís or Tenantís name but for the account of Tenant, for such term or terms (which may be greater or less than the period which would otherwise have constituted the balance of the term of this Lease) and on such conditions and upon such other terms (which may include concessions of free Rent and alteration and repair of the Premises) as Landlord, in its absolute discretion, may determine and Landlord may collect and receive the Rents therefor. Landlord shall in no way be 19 responsible or liable for any failure to relet the Premises, or any part thereof, or for any failure to collect any Rent due upon such reletting, but Landlord shall use commercially reasonable efforts to mitigate its damages. No such reentry or taking possession of the Premises by Landlord shall be construed as an election on Landlordís part to terminate this Lease unless a written notice of such intention be given to Tenant. No notice from Landlord hereunder or under a forcible entry and detainer statute or similar law shall constitute an election by Landlord to terminate this Lease unless such notice specifically so states. Landlord reserves the right following any such reentry and/or reletting to exercise its right to terminate this Lease by giving Tenant such written notice, in which event the Lease will terminate as specified in said notice. If Landlord elects to take possession of the Premises as provided in Paragraph 23a above without terminating the Lease, Tenant shall pay to Landlord (i) the Rent and other sums as herein provided, which would be payable hereunder if such repossession had not occurred, less (ii) the net proceeds, if any, of any reletting of the Premises after deducting all of Landlordís expenses incurred in connection with such reletting, including, but without limitation, all repossession costs, brokerage commissions, legal expenses, at to rneysí fees, expenses of employees, alteration, remodeling, and repair costs and expenses of preparation for such reletting. Unpaid installments of rent or other sums shall bear interest from the date due at the rate of twenty percent (20%) per annum.
Core diagnostic features are evident in the developmental period heart attack 14 year old quality innopran xl 80 mg, but intervention blood pressure 9460 buy 40 mg innopran xl amex, compensation blood pressure for seniors buy innopran xl cheap online, and current supports may mask difficulties in at least some contexts. Manifestations of the disorder also vary greatly de≠ pending on the severity of the autistic condition, developmental level, and chronological age; hence, the term spectrum. The impairments in communication and social interaction specified in Criterion A are pervasive and sustained. Many individuals have language deficits, ranging from complete lack of speech through language delays, poor comprehension of speech, echoed speech, or stilted and overly literal language. What language exists is often one-sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse. In adults without intellectual disabilities or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties processing and re≠ sponding to complex social cues. Adults who have developed compensation strategies for some social challenges still struggle in novel or unsupported situations and suffer from the effort and anxiety of con≠ sciously calculating what is socially intuitive for most individuals. Deficits in nonverbal communicative behaviors used for social interaction are mani≠ fested by absent, reduced, or atypical use of eye contact (relative to cultural norms), ges≠ tures, facial expressions, body orientation, or speech in to nation. Individuals may learn a few functional gestures, but their reper to ire is smaller than that of others, and they often fail to use expressive gestures spontaneously in com≠ munication. Among adults with fluent language, the difficulty in coordinating nonverbal communication with speech may give the impression of odd, wooden, or exaggerated "body language" during interactions. Deficits in developing, maintaining, and understanding relationships should be judged against norms for age, gender, and culture. There may be absent, reduced, or atyp≠ ical social interest, manifested by rejection of others, passivity, or inappropriate ap≠ proaches that seem aggressive or disruptive. These difficulties are particularly evident in young children, in whom there is often a lack of shared social play and imagination. Older individuals may struggle to understand what behavior is considered appropriate in one situation but not another. There may be an apparent preference for solitary activities or for interacting with much younger or older people. Frequently, there is a desire to establish friendships without a complete or realistic idea of what friendship entails. Relationships with siblings, co-workers, and caregivers are also important to consider (in terms of reciprocity). Autism spectrum disorder is also defined by restricted, repetitive patterns of behavior, interests, or activities (as specified in Criterion B), which show a range of manifestations according to age and ability, intervention, and current supports. Excessive adherence to rou≠ tines and restricted patterns of behavior may be manifest in resistance to change. Highly restricted, fixated interests in autism spectrum disorder tend to be abnormal in intensity or focus. Some fascinations and routines may relate to apparent hy≠ per or hyporeactivity to sensory input, manifested through extreme responses to specific sounds or textures, excessive smelling or to uching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme re≠ action to or rituals involving taste, smell, texture, or appearance of food or excessive food restrictions are common and may be a presenting feature of autism spectrum disorder. Many adults with autism spectrum disorder without intellectual or language disabili≠ ties learn to suppress repetitive behavior in public. Special interests may be a source of pleasure and motivation and provide avenues for education and employment later in life. Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests, or activities were clearly present during childhood or at some time in the past, even if symp to ms are no longer present. Criterion D requires that the features must cause clinically significant impairment in so≠ cial, occupational, or other important areas of current functioning. Standardized behavioral diagnostic instruments with good psychometric properties, including caregiver interviews, questionnaires and clinician observation measures, are available and can improve reliability of diagnosis over time and across clinicians. Associated Features Supporting Diagnosis Many individuals with autism spectrum disorder also have intellectual impairment and/or language impairment. Mo to r deficits are often present, in≠ cluding odd gait, clumsiness, and other abnormal mo to r signs. Adolescents and adults with autism spec≠ trum disorder are prone to anxiety and depression. Some individuals develop cata to nic-like mo to r behavior (slowing and "freezing" mid-action), but these are typically not of the mag≠ nitude of a cata to nic episode. However, it is possible for individuals with autism spectrum disorder to experience a marked deterioration in mo to r symp to ms and display a full cata≠ to nic episode with symp to ms such as mutism, posturing, grimacing and waxy flexibility.