A child may participate in family therapy to deal with the loss of a sibling and use individual treatment to address issues of personal ambivalence and guilt related to the death gastritis diet education effective 10 mg maxolon. Explaining that medication does not cure grief and often does not reduce the intensity of some symptoms (separation distress) can help gastritis diet herbs buy maxolon 10 mg free shipping. Offering to call members of pastoral care teams or their own spiritual leader can be a real support to them and aid in decision-making gastritis vs gerd cheap 10mg maxolon. Families have found it important to have their beliefs and their need for hope acknowledged in end-of-life care gastritis and dyspepsia cheap 10mg maxolon otc. The majority of patients report welcoming discussions on spirituality, which may help individual patients cope with illness, disease, dying, and death. Health care providers should not impose their own religious or antireligious beliefs on patients, but rather should listen respectfully to their patients. By responding to spiritual needs, physicians may better aid their patients and families in end-of-life care and bereavement and take on the role of healers. Since the death of a child is contrary to everything for which a pediatrician strives, the death of a patient can cause a grief reaction in physicians that is comparable to the death of a loved one, resulting in emotions of sadness, anger, guilt, and occasionally, relief. A medical culture in which health care providers acknowledge their own grief and mourning and select ways to address it is important. Getting regular exercise, maintaining good nutrition, getting adequate sleep, meditating, spending time with family and friends, taking time for journaling and self-reflection, participating in hobbies, and taking vacations are all examples of self-care. They need to maintain their inner strength and resilience in order to be effective in their profession. The way that a health care professional integrates the death of a child can change this experience from a very tragic and stressful one, leading to burnout, to a rewarding and memorable experience, in which he or she functions as a true healer to a family. Medication, as a first line of defense, rarely proves useful in normal or uncomplicated grief reactions. In certain situations (severe sleep disruption, incapacitating anxiety, or intense hyperarousal), use of an anxiolytic or antidepressant medication for symptom relief and to provide the patient with the emotional energy to mourn may help. Medication used in conjunction with some form of psychotherapy, and in consultation with a psychopharmacologist, has optimal results. Children who are refugees and may have experienced war, violence, or personal torture deserve special mention. These children, while often resilient, may experience post-traumatic stress disorder if exposures were severe or repeated. Sequelae such as depression, anxiety, and grief need to be addressed, and mental health therapy is indicated. Cognitive behavioral treatment, use of journaling and narratives to bear witness to the experiences, and use of translators may be essential. BiBliography American Academy of Child and Adolescent Psychiatry: Helping children after a disaster (website). American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health: How pediatricians can respond to the psychosocial implications of disasters, Pediatrics 103:521Â523, 1999. Brickell C, Munir K: Grief and its complications in individuals with intellectual disability, Harv Rev Psychiatry 16:1Â12, 2008. Ehntholt K, Yule W: Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma, J Child Psychol Psychiatry 47:1197Â1210, 2006. Kennedy C, McIntyre R, Worth A, et al: Supporting children and families facing the death of a parent: part 1, Int J Palliat Nurs 14:162Â168, 2008. Monroe-Blum H, Boyle M, Offord D, et al: Immigrant children: psychiatric disorder, school performance and service utilization, Am J Orthopsychiatry 59:510, 1989. Saldinger A, Cain A, Porterfield K: Managing traumatic stress in children anticipating parental death, Psychiatry 66:168Â181, 2003. Tennant C: Parental loss in childhood: its effect in adult life, Arch Gen Psychiatry 45:1045Â1050, 1988. Sleep Medicine IntroductIon Sleep regulation involves the simultaneous operation of two basic highly coupled processes that govern sleep and wakefulness (the "two process" sleep system). The homeostatic process ("Process S"), primarily regulates the length and depth of sleep, and may be related to the accumulation of adenosine and other sleeppromoting chemicals ("somnogens"), such as cytokines, during prolonged periods of wakefulness. This sleep pressure appears to build more quickly in infants and young children, thus limiting the duration of sustained wakefulness during the day and necessitating periods of daytime sleep. The endogenous circadian rhythm ("Process C"), influences the internal organization of sleep and timing and duration of daily sleep-wake cycles, and govern predictable patterns of alertness throughout the 24 hr day. Because the human circadian clock is actually slightly longer than 24 hr, intrinsic circadian rhythms must are synchronized or "entrained" to the 24-hr day cycle by environmental cues called zeitgebers. Circadian rhythms are also synchronized by other external time cues, such as timing of meals and alarm clocks. The relative level of sleepiness (sleep propensity) or alertness existing at any given time during a 24-hr period is partially determined by the duration and quality of previous sleep, as well as time awake since the last sleep period (the homeostatic or "sleep drive"). Interacting with this "sleep homeostat" is the 24 hr cyclic pattern or rhythm characterized by clock-dependent periods of maximum sleepiness ("circadian troughs") and maximum alertness ("circadian nadirs"). There are 2 periods of maximum sleepiness, 1 in the late afternoon (3:00-5:00 pm) and one towards the end of the night (3:00-5:00 am), and 2 periods of maximum alertness, 1 in mid-morning and 1 in the evening, just prior to sleep onset (the so-called second wind). Another basic principle of sleep physiology relates to the consequences of the failure to meet basic sleep needs, termed insufficient/inadequate sleep or sleep loss. Adequate sleep is a biologic imperative that appears necessary for sustaining life as well as for optimal functioning. Adequate amounts of both of these sleep stages are necessary for optimal learning. Partial sleep loss (sleep restriction) on a chronic basis accumulates in what is termed a sleep debt and produces deficits equivalent to those seen under conditions of total sleep deprivation. If the sleep debt becomes large enough and is not voluntarily paid back (by obtaining adequate recovery sleep), the body may respond by overriding voluntary control of wakefulness, resulting in periods of decreased alertness, dozing off, and napping, that is excessive daytime sleepiness. The sleep-deprived individual may also experience very brief (several seconds) repeated daytime microsleeps of which he or she may be completely unaware, but which nonetheless may result in significant lapses in attention and vigilance. There is also a relationship between the amount of sleep restriction and performance, with decreased performance correlating with decreased sleep. Both insufficient quantity and poor quality of sleep in children and adolescents usually result in excessive daytime sleepiness and decreased daytime alertness levels. Sleepiness may be recognizable as drowsiness, yawning, and other classic "sleepy behaviors," but can also be manifested as mood disturbance, including complaints of moodiness, irritability, emotional lability, depression, and anger; fatigue and daytime lethargy, including increased somatic complaints (headaches, muscle aches); cognitive impairment, including problems with memory, attention, concentration, decision-making, and problem solving; daytime behavior problems, including overactivity, impulsivity, and noncompliance; and academic problems, including chronic tardiness related to insufficient sleep and school failure resulting from chronic daytime sleepiness. To evaluate sleep problems, it is important to have an understanding of what constitutes "normal" sleep in children and adolescents. Sleep disturbances, as well as many characteristics of sleep itself, have some distinctly different features in children from sleep and sleep disorders in adults. In addition, changes in sleep architecture and the evolution of sleep patterns and behaviors reflect the physiologic/chronobiologic, developmental, and social/environmental changes that are occurring across childhood. These trends may be summarized as the gradual assumption of more adult sleep patterns as children mature: · A decline in the average 24 hr sleep duration from infancy through adolescence, which involves a decrease in both diurnal and nocturnal sleep amounts. There is a dramatic decline in daytime sleep (scheduled napping) by 5 yr, with a less marked and more gradual continued decrease in nocturnal sleep amounts into late adolescence. Less common causes of sleep disturbance in childhood involve inappropriate timing of the sleep period (as occurs in circadian rhythm disturbances), or primary disorders of excessive daytime sleepiness (central hypersomnias such as narcolepsy). Insufficient sleep is usually the result of difficulty initiating (delayed sleep onset) and/or maintaining sleep (prolonged night wakings), but, especially in older children and adolescents, may also represent a conscious lifestyle decision to sacrifice sleep in favor of competing priorities, such as homework and social activities. The underlying causes of sleep onset delay/prolonged night wakings or sleep fragmentation may in turn be related to primarily behavioral factors (bedtime resistance resulting in shortened sleep duration) and/or medical causes (obstructive sleep apnea causing frequent, brief arousals). It should be noted that certain pediatric populations are relatively more vulnerable to acute or chronic sleep problems. These include children with medical problems, including chronic illnesses, such as cystic fibrosis, asthma, and rheumatoid arthritis, and acute illnesses, such as otitis media; children taking medications or ingesting substances with stimulant. No established nocturnal/diurnal pattern in the 1st few wk; sleep is evenly distributed throughout the day and night, averaging 8. Safe sleep practices for infants: Place the baby on his or her back to sleep at night and during nap times. Place the baby on a firm mattress with a well-fitting sheet in a safety-approved crib. Do not use pillows or comforters Cribs should not have corner posts over 116 in high or decorative cut-outs. The capacity to self-soothe begins to develop in the 1st 12 wk of life, and is a reflection of both neurodevelopmental maturation and learning. Sleep consolidation, or "sleeping through the night," is usually defined by parents as a continuous sleep episode without the need for parental intervention. Infants develop the ability to consolidate sleep between 6 wk to 3 mo Cognitive, motor, social, language developmental issues impact on sleep Nighttime fears develop; transitional objects, bedtime routines important Persistent co-sleeping tends to be highly associated with sleep problems in this age group Sleep problems may become chronic Most sleep issues that are perceived as problematic at this stage represent a discrepancy between parental expectations and developmentally appropriate sleep behaviors.
We have made a beautiful (we hope beautiful) model of consciousness in terms of brain hardware and software gastritis from ibuprofen cheap 10mg maxolon fast delivery. Now we need to remember again that gastritis low carb diet order maxolon 10 mg visa, while the brain can be modeled by a computer gastritis helicobacter symptoms 10 mg maxolon with mastercard, the model is never the whole system gastritis diet ïåðåâîä÷èê buy maxolon 10 mg free shipping. Such experiences are routinely triggered by advanced yoga practice, and they also occur spontaneously during what is called "near-death" or "clinical death" in which the patient appears to die, by all medical standards, but is revived by modern resuscitation techniques. They are also reported in shamanic traditions all over the world and by many "occultists" in our own society. Example: One day in 1973, during a neuro-programming experiment, I "saw" something happening to my son at exactly that time in Arizona, over 500 miles away. We can say that my "astral body" actually traveled to Arizona; this is the occultist theory. We can more conservatively say that I developed extrasensory perception and "saw" Arizona without "going" there; there are many parapsychologists who prefer this third-circuit map of the Sth-Circuit experience. We can try to aver that I only "happened" to think of that scene while it was happening, by synchronicity; this is the Jungian approach. Or we can sweep it under the carpet by muttering "mere coincidence" or "sheer coincidence;" which is the traditional Rationalist approach. The Whole System, even the parts that are separated by cosmic distances, functions as a Whole System. Now, such faster-than-light communication seems to be forbidden by Special Relativity, which makes a problem. And yet we cannot dispense with Special Relativity either, because the mathematics there is equally flawless and the experiments are legion that confirm it. Two solutions have been proposed and both assume that the "communication" involved in Bellian transmissions does not involve energy, since it is energy that cannot move faster than light. Edward Harris Walker suggests that what does move faster than light, and holds the Whole System together, is "consciousness. Pure information, in the mathematical sense, does not require energy; it is that which orders energy. Sarfatti explains his theory as follows: Imagine that your brain is a computer, as modern neurology suggests. Now imagine that the whole universe is a big computer, a mega-computer, as John Lilly has proposed. The highest varieties of shamanic and yogic consciousness seem to begin from dilation beyond the immediate ("outofbody- experience") and dilate, rapidly and dizzily, much further, to union with the smallest and the largest-the "Cosmic Mind" in short. It is hard to avoid hyperbole when talking of such matters, but everything one can associate with the idea of Oneness With God-or Oneness with "Everything"-is part of what is experienced in the vistas, beyond space-time, of this meta-physiological circuit. Beethoven says it for all of them, without words, in the fourth movement of the Ninth Symphony. Consciousness or information perceived as coherent Intelligence expanding to infinity in all directions. The Right/Left Capitalist/ Socialist establishments are psychologically unprepared for our emerging situation in Time and Space. Esfandiary, Upwingers According to Patanjali, there are seven "limbs" to yoga, or as we would say seven steps or stages. First is asana, which consists of holding a single posture (usually sitting) for prolonged periods of time. This is an attempt, in our terminology, to stabilize the bio-survival circuit by drowning it in monotony. Eventually, an "internal peace" is reached, which signifies the atrophying of all background levels of "unconscious" or unnoticed bio-survival anxiety. In other schools, since asana is so monotonous and slowworking and because war (second-circuit mammalian struggles over territory) so common among domesticated primates, an alternative method of stabilizing the biosurvival circuit is used: martial arts. We have already commented on the efficiency of this breathing technique in quieting and mellowing-out secondcircuit emotional programs. In practice, this is beyond the powers of most students, so the majority of yoga teachers substitute mantra, which is concentration (by repetition) on a single sentence, usually nonsensical, such as "Hare Krishna Hare Krishna Krishna Krishna Hare Hare" or "Aum Tat Sat Aum" or whatever. Either practice, dharana or mantra, stops the third-circuit "internal monologue," if persisted in for long enough periods each day. The Western mystical equivalent is Cabala, the most complicated "Jewish joke" ever invented. Briefly, Cabala exhausts the third, semantic circuit by setting it to solve intractable numerological and verbal problems. The Far Eastern equivalent is the Zen Koan, which serves the same function in a less maniacally systematic way than Cabala. When the student has acquired sufficient detachment from first-circuit anxieties, second-circuit emotions and thirdcircuit reality-maps, by way of asana, pranayama and dharana or mantra, Patanjali recommends the practice of yama. The ultimate of yama is to lose all interest in both the social and sexual aspects of the fourth circuit; to cease to care at all about family, tribal or societal matters. This is accomplished by self-denial, which is easier for those skilled in asana, pranayama and dharana, but still requires intense determination. Some take a short-cut at this point, discovered after Patanjali or not known to him, by having themselves locked up in caves. Such isolation, as indicated earlier, helps vastly in bleaching out all four hominid circuits. An alternative, for those not attracted to either celibacy or becoming hermits, is Tantra, invented in northern India around the time of Patanjali. This simply transmutes the fourth circuit by ceremonial, physiological arid "magick" (self-hypnotic) explosion of the (prolonged) sexual act into fifth-circuit neurosomatic rapture. For those following the orthodox path of Patanjali, the fifth circuit is imprinted by niyama, which signifies "supercontrol" or "no-control," being the paradoxical state of being spontaneous deliberately. We hypothesize that the bio-energies have to discharge somewhere, and then when one has driven them out of the first circuit by asana, out of the second circuit by pranayama, out of the third circuit by dharana or mantra, and out of the fourth circuit by yama, they are driven explosively upward into fifth-circuit neurosomatic illumination. The sixth step in yoga, according to Patanjali, is dhyana, which means "meditation" only in the roughest way. One can make dhyana on anything; yogis talk of making dhyana on a tree or a dog, just as don Juan Matus, the Mexican shaman, talks of becoming one with a coyote or a star in the books of Castaneda. The seventh step in yoga is Samadhi, from sam, (union; cognate of Greek syn) and Adhis, the Lord (cognate, Hebrew Adonai, Greek Adonis). Here Patanjali and his successors are in violent dispute, some claiming there is only one Samadhi, others claiming two or three or many. Since this corresponds with the opening and imprinting of the neurogenetic circuit, we must opt for the opinion that there are many Samadhi, depending on which or how many of the Godly archetypes of the genetic archives are imprinted. Catholic mystics make Samadhi on the Virgin, Sufis on Allah, Aleister Crowley on Pan, etc. It was from this second order or meta-physiological Samadhi that Gandhi said, "God is in the rock, too-in the rock! Bucke who said after his own Eighth-Circuit Samadhi that the universe "is not a dead machine but a living presence. Voltaire may have been exaggerating when he said that to understand the mathematical meaning of infinity, consider the extent of human stupidity; but the situation is almost that bad. Millions have been murdered by stupid leaders or stupid mobs, for stupid reasons, in every century; and the bizarre (accidentally imprinted) reality-tunnels which make this possible continue to rule us and robotize us. Nor is stupidity the exclusive possession of one group or another; you do not need a "vocation" for it as you do for the priesthood. It seems to be a contagious socio-semantic disturbance which afflicts all of us at one time or another. As we have already mentioned an exact measurement of the extent of stupidity among the learned is provided by the fact that every scientific revolution takes one generation. Elderly scientists hardly ever accept a new theory, however good it is, and the revolution is only completed when a second generation, free of the old imprints, with vulnerable neurons, imprints the new reality-map. But if science, the paradigm of rationality, is infested with enough stupidity to cause this general one-generation timelag, what can we say of politics, economics and religion? Indeed, it was through contemplation of religious history that Voltaire was led to his conclusion that human stupidity approximates to the infinite. Let us just summarize the matter by saying that stupidity has murdered and imprisoned more geniuses (and more ordinary people), burned more books, slaughtered more populations, and blocked progress more effectively than any other force in history.
Such policies (Baby Friendly Hospital) have been shown 4 to significantly increase breast-feeding rates (see Chapter 94) nervous gastritis diet discount 10mg maxolon with mastercard. After discharge atrophic gastritis definition order 10mg maxolon fast delivery, home visits by nurses and lactation counselors can reduce early feeding problems and identify emerging medical conditions in either mother or baby chronic gastritis omeprazole order maxolon 10mg without prescription. Infants requiring transport to another hospital should be brought to see the mother first gastritis kronik cheap 10 mg maxolon visa, if at all possible. On discharge home, fathers can shield mothers from unnecessary visits and calls and take over household duties, allowing mothers and infants time to get to know each other without distractions. The first office visit should occur during the first 2 wk after discharge to determine how smoothly the mother and infant are making the transition to life at home. Babies who are discharged early, those who are breast-feeding, and those who are at risk for jaundice should be seen 1 to 3 days after discharge. Optimal Practices Assessing Parent-Infant Interactions During a feeding or when infants are alert and face-to-face with their parents, it is normal for them to appear absorbed in one another. Alternatively, the infant may be ready to interact, whereas the mother may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long-term benefits to the child. Parents might learn that they need to undress their infant to increase the level of arousal or to swaddle the infant to reduce overstimulation by containing random arm movements. Some activities previously thought to be "primitive" or "reflexive" result from complex systems. Swallowing, rather than a simple reflex, results from a complex highly coordinated process involving multiple levels of neural control distributed among several physiologic systems whose nature and relationships mature throughout the 1st year of life. Substantial learning of the basic tools of language (phonology, word segmentation) occurs during infancy. Speech processing in older individuals requires defined and precise neuronal networks; imaging studies have revealed that the infant brain possesses a structural and functional organization similar to that of adults, leading to the belief that structural neurologic processing of speech may guide infants to discover the properties of his or her native language. Myelination of the cortex begins at 8 mo gestation and is nearly complete by age 2 yr; much of this process occurs during infancy. Given the importance of iron and other nutrients in myelination, adequate stores throughout infancy are critical (see Chapter 42). Inadequate dietary intake, insufficient interactions with caregivers, or both may alter experience-dependent processes that are critical to brain structure development and function during infancy. Although some of these processes may be delayed, as the periods of plasticity close during the rapid developmental changes occurring in infancy, more permanent deficits may result. The concept of developmental trajectories recognizes that complex skills build on simpler ones; it is also important to realize how development in each domain affects functioning in 1. Physical growth parameters and normal ranges for attainable weight, length, and head circumference are found in the Centers for Disease Control and Prevention growth charts 2. Table 8-1 presents an overview of key milestones by domain; Table 8-2 presents similar information arranged by age. Parents often seek information about "normal development" during this period and should be directed to reliable sources, including the American Academy of Pediatrics website. Physiologic changes allow the establishment of effective feeding routines and a predictable sleep-wake cycle. The social interactions that occur as parents and infants accomplish these tasks lay the foundation for cognitive and emotional development. Nutrition improves as colostrum is replaced by higher-fat breast milk, as infants learn to latch on and suck more efficiently, and as mothers become more comfortable with feeding techniques. Infants regain or exceed birthweight by 2 wk of age and should grow at approxi4 mately 30 g (1 oz)/day during the 1st mo (see Table 13-1). Limb movements consist largely of uncontrolled writhing, with apparently purposeless opening and closing of the hands. Eye gaze, head turning, and sucking are under better control and thus can be used to demonstrate infant perception and cognition. Initially, sleep and wakefulness are evenly distributed throughout the 24-hr day. Neurologic maturation accounts for the consolidation of sleep into blocks of 5 or 6 hr at night, with brief awake, feeding periods. Learning also occurs; infants whose parents are consistently more interactive and stimulating during the day learn to concentrate their sleeping during the night. They can recognize facial expressions (smiles) as similar, even when they appear on different faces. They also can match abstract properties of stimuli, such as contour, intensity, or temporal pattern, across sensory modalities. Infants at 2 mo of age can discriminate rhythmic patterns in native vs non-native language. Infants appear to seek stimuli actively, as though satisfying an innate need to make sense of the world. These phenomena point to the integration of sensory inputs in the central nervous system. Caretaking activities provide visual, tactile, olfactory, and auditory stimuli; all of these support the development of cognition. Infants habituate to the familiar, attending less to repeated stimuli and increasing their attention to novel stimuli. Crying occurs in response to stimuli that may be obvious (a soiled diaper), but are often obscure. Infants who are consistently Bangs 2 cubes Uncovers toy (after seeing it hidden) Egocentric symbolic play. Cross-cultural studies show that in societies in which infants are carried close to the mother, babies cry less than in societies in which babies are only periodically carried. Crying normally peaks at about 6 wk of age, when healthy infants may cry up to 3 hr/day, then decreases to 1 hr or less by 3 mo. Hunger generates increasing tension; as the urgency peaks, the infant cries, the parent offers the breast or bottle and the tension dissipates. Infants fed "on demand" consistently experience this link between their distress, the arrival of the 6. Mutual regulation takes the form of complex social interchanges, resulting in strong mutual attachment and enjoyment. Between 3 and 4 mo of age, the rate of growth slows to approximately 20 g/day (see Table 13-1 and. Disappearance of the asymmetric tonic neck reflex means that infants can begin to examine objects in the midline and manipulate them with both hands (see Chapter 584). Waning of the early grasp reflex allows infants both to hold objects and to let them go voluntarily. The quality of spontaneous movements also changes, from larger writhing to smaller, circular movements that have been described as "fidgety. Once infants can hold their heads steady while sitting, they can gaze across at things rather than merely looking up at them, and can begin taking food from a spoon. At the same time, maturation of the visual system allows greater depth perception. In this period, infants achieve stable state regulation and regular sleep-wake cycles. Total sleep requirements are approximately 14-16 hr/24 hr, with about 9-10 hr concentrated at night and 2 naps/day. The sleep cycle remains shorter than in adults (50-60 min vs approximately 90 min). As a result, infants arouse to light sleep or wake frequently during the night, setting the stage for behavioral sleep problems (see Chapter 17). Most infants fed on a fixed schedule quickly adapt their hunger cycle to the schedule. Those who cannot because they are temperamentally prone to irregular biologic rhythms experience periods of unrelieved hunger as well as unwanted feedings when they already feel full. These infants often show increased irritability and physiologic instability (spitting, diarrhea, poor weight gain) as well as later behavioral problems.
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Although precipitating factors for depression are not clear gastritis eggs generic maxolon 10 mg free shipping, many patients experience stressful events in the 6 months preceding the onset of the episode chronic gastritis histology maxolon 10 mg free shipping. In addition to antidepressants gastritis diet potatoes buy 10mg maxolon mastercard, other drug therapy may include anxiolytics gastritis diet of the stars buy generic maxolon 10mg on-line, antipsychotics, and lithium. Decision Maximum certification - 1 year Recommend to certify if: the driver: · · · · Completes an appropriate symptom-free waiting period. Page 198 of 260 Monitoring/Testing At least every 2 years the driver with a history of a major mood disorder should have evaluation and clearance for commercial driving from a mental health specialist, such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving. Personality Disorders Any personality disorder characterized by excessive, aggressive, or impulsive behaviors warrants further inquiry for risk assessment to establish whether such traits are serious enough to adversely affect behavior in a manner that interferes with safe driving. A person is medially unqualified if the disorder is severe enough to have repeatedly been manifested by overt acts that interfere with safe operation of a commercial vehicle. The actual ability to drive safely and effectively should not be determined solely by diagnosis but instead by an evaluation focused on function and relevant history. Page 199 of 260 · Prominent negative symptoms, including substantially compromised judgment, attentional difficulties, suicidal behavior or ideation, or a personality disorder that is repeatedly manifested by overt, inappropriate acts. Schizophrenia and Related Psychotic Disorders Schizophrenia is the most severe condition within the spectrum of psychotic disorders. Individuals with chronic schizophrenia should not be considered medically qualified for commercial driving. Risks for Commercial Driving Clinical experience shows that a person who is actively psychotic may behave unpredictably in a variety of ways. For example, a person who is hearing voices may receive a command to do something harmful or dangerous, such as self-mutilation. Except for a confirmed diagnosis of schizophrenia, determination may not be based on diagnosis alone. Decision Maximum certification - 1 year Page 200 of 260 Recommend to certify if: the driver: · · · · Completes an appropriate symptom-free waiting period. Individuals with this condition tend to be severely incapacitated and frequently lack the cognitive skills necessary for steady employment, may have impaired judgment and poor attention, and have a high risk for suicide. Monitoring/Testing At least every 2 years, the driver with a history of mental illness with psychotic features should have evaluation and clearance for commercial driving from a mental health specialist, such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving. Drug Abuse and Alcoholism There is overwhelming evidence that drug and alcohol use and/or abuse interferes with driving ability. Although there are separate standards for alcoholism and other drug problems, in reality much substance abuse is polysubstance abuse, especially among persons with antisocial and some personality disorders. Alcohol and other drugs cause impairment through both intoxication and withdrawal. Episodic abuse of substances by commercial drivers that occurs outside of driving periods may still cause impairment during withdrawal. However, when in remission, alcoholism is not disabling unless transient or permanent neurological changes have occurred. Page 201 of 260 Alcohol and other drug dependencies and abuse are profound risk factors associated with personality disorders that may interfere with safe driving. Even in the absence of abuse, the commercial driver should be made aware of potential effects on driving ability resulting from the interactions of drugs with other prescription and nonprescription drugs and alcohol. If a driver has a current drinking problem, clinical alcoholism, or uses a Schedule I drug or other substance such as an amphetamine, a narcotic, or any other habit-forming drug, the effects and/or side effects may interfere with driving performance, thus endangering public safety. The examination is based on information provided by the driver (history), objective data (physical examination), and additional testing requested by the medical examiner. Page 202 of 260 Medical certification depends on a comprehensive medical assessment of overall health and informed medical judgment about the impact of single or multiple conditions on the whole person. Key Points for Medical Assessment for Drug Abuse and/or Alcoholism During the physical examination, you should ask the same questions as you would for any individual who is being assessed for psychological or behavior concerns. Regulations - You must review and discuss with the driver any "yes" answers Does the driver use: · · Alcohol, regularly and frequently? Recommendations - Questions that you may ask include Does the driver who uses alcohol: · · · Have a consumption pattern that indicates additional evaluation may be needed based on quantity per occasion or per day/week? Have a history of driver and/or family alcohol-related medical and/or behavioral problems? Does the driver who uses narcotic or habit-forming drugs have a: · · · · Therapeutic or habitual need? Voluntary, ongoing participation in a self-help program to support recovery is not disqualifying. Page 203 of 260 Regulations - You must evaluate On examination, does the driver have signs of alcoholism, problem drinking, or drug abuse, including: · · Tremor. Record Regulations - You must document discussion with the driver about · Any affirmative history, including if available: o o o · · Onset date, diagnosis. Potential negative effects of medication use, including over-the-counter medications, while driving. Necessary steps to correct the condition as soon as possible, particularly if the untreated condition could result in more serious illness that might affect driving. Medical fitness for duty includes the ability to perform strenuous labor and to have good judgment, impulse control, and problem-solving skills. Overall requirements for commercial drivers as well as the specific requirements in the driver role job description should be deciding factors in the certification process. Reasonable suspicion testing is conducted when a trained supervisor or company official observes behavior or appearance that is characteristic of drug and/or alcohol misuse. Random drug and/or alcohol testing is conducted on a random, unannounced basis just before, during, or just after performance of safety-sensitive functions. Return-to-duty and follow-up testing is conducted when an individual who has violated the prohibited drug and/or alcohol conduct standards returns to performing safety-sensitive duties. Employer responsibilities include: · · · · Implementing and conducting drug and alcohol testing programs. For more information see Federal Motor Carrier Safety Administration Web site. If the driver shows signs of alcoholism, have the driver consult a specialist for further evaluation. The ultimate responsibility rests with the motor carrier to ensure the driver is medically qualified and to determine whether a new medical examination should be completed. Waiting Period No recommended time frame You should not certify the driver until the driver has successfully completed counseling and/or treatment. Decision Maximum certification - 2 years Recommend to certify if: the driver with a history of alcoholism has: · · · No residual disqualifying physical impairment. Do not to certify if: the driver has: · · · · A current clinical diagnosis of alcoholism. Waiting Period No recommended time frame You should not certify the driver for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use and has completed any recertification requirements. Decision Maximum certification - 2 years Recommend to certify if: the driver with a history of drug abuse has: · · No residual disqualifying physical condition. Page 207 of 260 Do not to certify if: the driver uses: · · · · · · Schedule I controlled substances. Monitoring/Testing You have the option to certify for a period of less than 2 years if more frequent monitoring is required. Follow-up the driver should have at least biennial medical examinations or more frequently if indicated. The driver may experience an altered state of alertness, attention, or even temporary confusion. Other medications may cause physical symptoms such as hypotension, sedation, or increased bleeding that can interfere with task performance or put the driver at risk for gradual or sudden incapacitation. Combinations of medications and/or supplements may have synergistic effects that potentiate side effects, causing gradual or sudden incapacitation. The demands of commercial driving may complicate adherence to prescribed dosing intervals and precautions. Irregular meal timing, periods of sleep deprivation or poor sleep quality, and irregular or extended work hours can alter the effects of medicine and contribute to missed or irregular dosing. Three types of medications may be used by the commercial driver: · · · Prescription. Every year, more medications are available without prescription and provider supervision. As the medical examiner, your fundamental obligation is to establish whether a driver uses one or more medications and supplements that have cognitive or physical effects or side effects that interfere with safe driving, thus endangering public safety.
