See Health Maintenance ( Health Maintenance ) for SmartPhrase data on HM.


Meditation: A simple, fast way to reduce stress
Meditation helps you live in the moment, letting go of regrets of the past or worries of the future.  

If stress has you anxious, tense and worried, consider trying meditation. Spending even a few minutes in meditation can restore your calm and inner peace. 
Anyone can practice meditation. It's simple and inexpensive, and it doesn't require any special equipment. And you can practice meditation wherever you are — whether you're out for a walk, riding the bus, waiting at the doctor's office or even in the middle of a difficult business meeting. 
Understanding meditation
Meditation has been practiced for thousands of years. Meditation originally was meant to help deepen understanding of the sacred and mystical forces of life. These days, meditation is commonly used for relaxation and stress reduction. 
Meditation is considered a type of mind-body complementary medicine. Meditation produces a deep state of relaxation and a tranquil mind. During meditation, you focus your attention and eliminate the stream of jumbled thoughts that may be crowding your mind and causing stress. This process results in enhanced physical and emotional well-being. 
Meditation helps augment alpha and theta waves in the brain to bring a sense of well-being and facilitate an internal environment of healing.
Benefits of meditation
Meditation can give you a sense of calm, peace and balance that benefits both your emotional well-being and your overall health. And these benefits don't end when your meditation session ends. Meditation can help carry you more calmly through your day and can even improve certain medical conditions. 
Meditation and emotional well-being
When you meditate, you clear away the information overload that builds up every day and contributes to your stress. 
The emotional benefits of meditation include: 
Gaining a new perspective on stressful situations 
Building skills to manage your stress 
Increasing self-awareness 
Focusing on the present 
Reducing negative emotions
Meditation and illness
Meditation also might be useful if you have a medical condition, especially one that may be worsened by stress. While a growing body of scientific research supports the health benefits of meditation, some researchers believe it's not yet possible to draw conclusions about the possible benefits of meditation. 
With that in mind, some research suggests that meditation may help such conditions as: 
Anxiety disorders 
Binge eating 
Heart disease 
High blood pressure 
Sleep problems 
Substance abuse
 Meditation isn't a replacement for traditional medical treatment. But it may be a useful addition to your other treatment. 
Types of meditation
Meditation is an umbrella term for the many ways to a relaxed state of being. There are many types of meditation and relaxation techniques that have meditation components. All share the same goal of achieving inner peace. Find a method that suits your personality.
Ways to meditate can include: 
Guided meditation. Sometimes called guided imagery or visualization, with this method of meditation you form mental images of places or situations you find relaxing. You try to use as many senses as possible, such as smells, sights, sounds and textures. You may be led through this process by a guide or teacher. 
Mantra meditation. In this type of meditation, you silently repeat a calming word, thought or phrase to prevent distracting thoughts. 
Mindfulness meditation. This type of meditation is based on being mindful, or having an increased awareness and acceptance of living in the present moment. You broaden your conscious awareness. You focus on what you experience during meditation, such as the flow of your breath. You can observe your thoughts and emotions but let them pass without judgment. 
Qi gong. This practice generally combines meditation, relaxation, physical movement and breathing exercises to restore and maintain balance. Qi gong (CHEE-gung) is part of traditional Chinese medicine. 
Tai chi. This is a form of gentle Chinese martial arts. In tai chi (TIE-chee), you perform a self-paced series of postures or movements in a slow, graceful manner while practicing deep breathing. 
Transcendental meditation. You use a mantra, such as a word, sound or phrase repeatedly silently, to narrow your conscious awareness and eliminate all thoughts from your mind. You focus exclusively on your mantra to achieve a state of perfect stillness and consciousness. 
Yoga. You perform a series of postures and controlled breathing exercises to promote a more flexible body and a calm mind. As you move through poses that require balance and concentration, you're encouraged to focus less on your busy day and more on the moment
Prayer.  Spending a few moments in the presence of the Higher Power.  This can easily be done upon waking, at bedtime, any time, any where.
Sports.  Athletes know that if they are not 'in the moment' they don't perform as well.  Sports can be meditative also.
Elements of meditation
Different types of meditation may include different features to help you meditate. These may vary depending on whose guidance you follow or who's teaching a class. Some of the most common features in meditation include: 
Focused attention. Focusing your attention is generally one of the most important elements of meditation. Focusing your attention is what helps free your mind from the many distractions that cause stress and worry. You can focus your attention on such things as a specific object, an image, a mantra, or even your breathing. 
Relaxed breathing. This technique involves deep, even-paced breathing using the diaphragm muscle to expand your lungs. The purpose is to slow your breathing, take in more oxygen, and reduce the use of shoulder, neck and upper chest muscles while breathing so that you breathe more efficiently. 
A quiet setting. If you're a beginner, practicing meditation may be easier if you're in a quiet spot with few distractions — no television, radios or cellphones. As you get more skilled at meditation, you may be able to do it anywhere, especially in high-stress situations where you benefit the most from meditation, such as a traffic jam, a stressful work meeting or a long line at the grocery store. 
A comfortable position. You can practice meditation whether you're sitting, lying down, walking or in other positions or activities. Just try to be comfortable so that you can get the most out of your meditation.
Everyday ways to practice meditation
Don't let the thought of meditating the "right" way add to your stress. Sure, you can attend special meditation centers or group classes led by trained instructors. But you also can practice meditation easily on your own. 
And you can make meditation as formal or informal as you like — whatever suits your lifestyle and situation. Some people build meditation into their daily routine. For example, they may start and end each day with an hour of meditation. But all you really need is a few minutes of quality time for meditation. 
Here are some ways you can practice meditation on your own, whenever you choose:  
Breathe deeply. This technique is good for beginners because breathing is a natural function. Focus all attention on your breathing. Concentrate on feeling and listening as you inhale and exhale through your nostrils. Breathe deeply and slowly. When your attention wanders, gently return your focus to your breathing. 
Scan your body. When using this technique, focus attention on different parts of your body. Become aware of your body's various sensations, whether that's pain, tension, warmth or relaxation. Combine body scanning with breathing exercises and imagine breathing heat or relaxation into and out of different parts of your body. 
Repeat a mantra. You can create your own mantra, whether it's religious or secular. Examples of religious mantras include the Jesus Prayer in the Christian tradition, the holy name of God in Judaism, or the om mantra of Hinduism, Buddhism and other Eastern religions. 
Walk and meditate. Combining a walk with meditation is an efficient and healthy way to relax. You can use this technique anywhere you're walking — in a tranquil forest, on a city sidewalk or at the mall. When you use this method, slow down the pace of walking so that you can focus on each movement of your legs or feet. Don't focus on a particular destination. Concentrate on your legs and feet, repeating action words in your mind such as lifting, moving and placing as you lift each foot, move your leg forward and place your foot on the ground. 
Engage in prayer. Prayer is the best known and most widely practiced example of meditation. Spoken and written prayers are found in most faith traditions. You can pray using your own words or read prayers written by others. Check the self-help or 12-step-recovery section of your local bookstore for examples. Talk with your rabbi, priest, pastor or other spiritual leader about resources. 
Read and reflect. Many people report that they benefit from reading poems or sacred texts, and taking a few moments to quietly reflect on their meaning. You also can listen to sacred music, spoken words or any music you find relaxing or inspiring. You may want to write your reflections in a journal or discuss them with a friend or spiritual leader. 
Focus your love and gratitude. In this type of meditation, you focus your attention on a sacred object or being, weaving feelings of love and gratitude into your thoughts. You can also close your eyes and use your imagination or gaze at representations of the object.
Building your meditation skills
Don't judge your meditation skills, which may only increase your stress. Meditation takes practice. Keep in mind, for instance, that it's common for your mind to wander during meditation, no matter how long you've been practicing meditation. If you're meditating to calm your mind and your attention wanders, slowly return to the object, sensation or movement you're focusing on. 
Experiment, and you'll likely find out what types of meditation work best for you and what you enjoy doing. Adapt meditation to your needs at the moment. Remember, there's no right way or wrong way to meditate. What matters is that meditation helps you with stress reduction and feeling better overall. 
--- end meditation ---

Parental discipline dot phrase: .discipline

Making Discipline Work The word discipline is so often used interchangeably with punishment that we tend to lose sight of its true purpose and meaning. “Discipline is not intended to be punitive,” explains Dr. George Comerci, an Arizona pediatrician and former president of the American Academy of Pediatrics. “The object is to teach self-control and to prepare teenagers for entering adulthood and society.” You and your youngster will both benefit if you approach discipline as a system of setting and enforcing effective limits through incentives and deterrents rather than issuing ultimatums. An ultimatum is a do-it-or-else statement: “Joe, put away your bike, or you can’t ride it for the rest of the day.” It is condescending to teens and may be interpreted as a challenge. Establishing boundaries, on the other hand, communicates respect. You spell out the desirable: "Joe, I want you to put away your bike…" Then specify a positive consequence for compliance: "If you put it away now, you can ride it later…" And a negative consequence for noncompliance: "But if you don't, you cannot ride it for the rest of the day." First parents must establish and clearly identify what constitutes permissible and unacceptable behavior in everything from conduct, to school performance, to curfew. Instead of calling these rules and regulations, let’s refer to them as a teenager’s rights and responsibilities. It may seem a small difference in semantics, but these terms more accurately reflect the goal of imposing discipline at home: to teach children the self-discipline they must master to achieve happiness and success in later years. Youngsters who have little or no structure at home may be the envy of their peers, but as Dr. Renée Jenkins observes, “They often feel ignored by their parents.” Teens will never admit to it, but secretly they want and need us to set limits—even if they don’t always abide by them. In time, most come to realize that we do so out of love, not merely to flex our adult muscles. Just don’t expect to receive any expressions of gratitude until they become parents themselves. Rules for Making Rules Adolescents, so intent on asserting their independence, tend to see themselves as tyrannized by rules, rules and more rules. Although consistency in the enforcement of your rules is key to discipline, not all rules are equally important. Now and then parents can bend the regulations pertaining to such matters as TV viewing, curfews, bedtime, dating, homework habits, car privileges and similar matters. Learning to prioritize household rules gives both you and your teenager room to practice the arts of negotiation and compromise. As Dr. Adele Hofmann explains, in a discussion of establishing a curfew: “It’s like buying a rug at a Turkish bazaar; you bargain your way down.” A curfew negotiation might proceed along these lines: “I’ve given a lot of thought to what your weeknight curfew should be during the summer. Nine o’clock seems fair.” “Nine o’clock? But Mom, all my friends get to stay out till eleven!” Suppressing your skepticism, you reply, “Well, I think eleven o’clock is much too late for a fifteen-year-old. What if we compromised and said ten o’clock? That gives you an extra hour...” As with a commercial transaction, it helps if you enter the negotiation with an idea of where you’re willing to end up. However, there should be no negotiation when it comes to restrictions imposed to safeguard youngsters from risky behaviors such as substance abuse, premature sexual activity and reckless driving. Your policy on matters that affect health, safety or well-being should be stated clearly. For example, make sure that your child understands that tobacco, alcohol or other drug use will not be tolerated, and that any breach of your trust will result in serious consequences. It’s wise to spell out your expectations early on in adolescence, if not sooner, to help avert problems down the road. And your chances of having these expectations met are higher if you are prepared to explain your decision. “I can’t ride my bike to the mall across town? But why not?” your teen is likely to demand. An appropriate response would be: “Because your father and I think that it’s too far away and there’s too much traffic. You can take the bus, but biking it is too dangerous. We love you, and we’re concerned about your safety.” Teenagers are more inclined to comply with a rule when they understand the logic behind it, as opposed to receiving a flat “Because I said so, that’s why.” How to Respond with Effective Discipline Article Body If your child shows signs of ADHD, it may mean that she cannot control her behavior on her own. In her hurry and excitement, she may be accident prone and may destroy property. To discipline a hyperactive child, you need to respond both effectively and constructively. If your actions are effective, your child’s behavior will improve as a result. If they are constructive, they also will help develop her self-esteem and make her more personable. The table below provides some examples of effective and constructive responses to common problems among hyperactive children. *Note: In all these situations, try to determine what influences might cause or prolong the behavior: Is the child in need of attention, tired, worried, or fearful? What is your own mood or behavior? Remember, you always should praise your child for good or improved effort. Child's Behavior* Your Responses Effective Constructive Temper Tantrums Walk away. Discuss the incident in an age-appropriate manner when child is calm. Overexcitement Distract with another activity. Talk about his behavior in an age-appropriate manner when he's calm. Hitting or biting Immediately remove him from situation or in anticipation of this behavior. Discuss consequences of his actions (pain, damage, bad feelings) to himself and others in an age-appropriate manner. Try one-word time-out after brief response. Not paying attention Establish eye contact to hold his attention. Make sure your expectations are age-appropriate for your child's developmental level (ask him to listen to a story for three minutes instead of ten; don't insist he sit through a full church service). Refuses to pick up toys Don't let him play until he does his job. Show him how to do the task and help him with it; praise him when he finishes. It is important to respond immediately whenever your child misbehaves and to make sure that everyone caring for her responds to these incidents in the same way. Discipline means teaching self-control. If done effectively, you will rarely need to use punishment. Do not spank or slap your child since it does not encourage her to control herself and may contribute to a continued negative self image and resentment toward you; at the same time, this approach tells her that it’s OK to strike other people. Instead, acknowledge and point out those times when she displays appropriate behaviors (“catching her being good”), and learn to actively ignore inappropriate behaviors that are not dangerous; this approach is far more effective in the long run. Children with ADHD can be very challenging to manage and parents may find they need help or coaching in how to effectively manage their child’s behaviors. Spanking Kids Can Make Them More Aggressive Later Children who are spanked frequently at age 3 are more likely to be aggressive when they’re 5, even when you account for possible confounding factors and the child’s level of aggression at age 3. The study, “Mothers’ Spanking of 3-Year-Old Children and Subsequent Risk of Children’s Aggressive Behavior,” in the May issue of Pediatrics (published online April 12), asked nearly 2,500 mothers how often they had spanked their 3-year-old child in the past month, as well as questions about their child’s level of aggression, demographic features such as child gender, and eight maternal parenting risk factors, such as parenting stress, depression, alcohol use, and the presence of other types of aggression within the family. Almost half (45.6 percent) of the mothers reported no spanking in the previous month, while 27.9 percent reported spanking one or two times, and 26.5 percent reported spanking more than twice. Mothers with more parenting risk factors were more likely to spank frequently. However, even after accounting for these potential confounding factors, frequent spanking at age 3 increased the odds of higher levels of aggression at age 5. Despite recommendations from the American Academy of Pediatrics against spanking, most parents in the U.S. approve of and have used corporal punishment as a form of child discipline. Researchers state that this study suggests that even minor forms of corporal punishment increase the risk for child aggressive behavior. A note on Violence in the Media from the American Academy of Family Physicians: Public outcry followed the 1999 shooting in a Littleton, Colo. school that left 15 students dead and 23 injured. In truth, however, homicides that occur at school, or on the way to and from school, represent only 1 percent of total homicides among youth aged 5-19.1 One can begin to appreciate the true toll of violence in the United States when comparing it with violence in other industrialized nations. In 1998, for instance, the United States experienced 35 times as many gun deaths per capita as England and 285 times as many as Japan.2 Overall, a US child is about 300 times as likely to die from a firearm as a child from a typical industrialized nation.3 Among Americans aged 15-34 years, two of the top three causes of death are homicide and suicide.4 In a given year, more US children will die from gunfire than will die from cancer, pneumonia, influenza, asthma, and HIV/AIDS combined.5 Other forms of violence, such as beating, stabbing, and rape also contribute significantly to US morbidity and mortality. Media Violence in the United States Violence is ubiquitous in American mass media. An average American youth will witness 200,000 violent episodes on television alone before age 18.6 Violence is often considerable, even in programs which are not advertised as violent. Overall, weapons appear on prime time television an average of 9 times each hour.7 An estimated 54 percent of American children can watch this programming from the privacy of their own bedrooms.8 Children’s shows are particularly violent. Saturday morning cartoons contain 20-25 violent acts per hour, about 6 times as many as prime time programs.9 Overall, 46 percent of TV violence occurs in cartoons.8 Additionally, these programs are more likely to juxtapose violence with humor (67 percent) and less likely to show the long-term consequences of violence (5 percent).8 Although some claim that cartoon violence is not as “real” and therefore not as damaging, cartoon violence has been shown to increase the likelihood of aggressive, antisocial behavior in youth.10 This makes sense in light of children’s developmental difficulty discerning the real from the fantastic.11 A Skewed Sense of Violence Media violence presents a picture significantly different from that of true violence. First, the sheer volume of violence is exaggerated; 66 percent of television programs contain violence.8 More significant, however, are the skewed contexts in which media present violence. In media portrayals, 75 percent of violent acts are committed without remorse, criticism, or penalty; 41 percent are associated with humor; 38 percent are committed by attractive perpetrators; and 58 percent involve victims who show no pain.8 This inappropriate presentation of violence leads to inappropriate expectations of youth with regard to true violence. In particular, three major attitudes are learned: aggression, desensitization, and victimization. Statistical analyses show what type of media violence most likely teaches each attribute: violent episodes associated with humor, weapons, and attractive perpetrators increase real-life aggression; humor-associated violence and graphic violence lead to real-life desensitization; and graphic violence and realistic violence tend to generate fear and a sense of victimization in viewers.8 1. Aggression That media violence leads to increased actual violence has been borne out by amassive body of literature. More than 1000 lab experiments, cross-sectional analyses, longitudinal studies, and epidemiologic studies support this hypothesis, as do meta-analyses.7,12-14 Many of these studies have additionally shown that certain populations are particularly sensitive to media violence. These include males, emotionally labile children, delinquent children, and children with developmental disabilities.10,15 2. Desensitization Media violence has also been shown to desensitize humans to violence. In one study, portrayals of violence against women in sexual contexts fostered callous attitudes toward victims of sexual and spousal abuse. Subjects viewed “slasher” films and were then asked, in a seemingly unrelated study, to observe and comment on a videotaped rape trial. After repeated viewing of the “slasher” films, subjects showed less sympathy toward victims of rape, perceived less violence in the films, perceived films as less violent toward women, and showed decreases in anxiety and depression due to the rape trial.16 3. Trauma and Victimization Media violence also leads to fear and a feeling of victimization. In one study, 75 percent of high school students reported media violence at moderate to high levels, and 10 percent sought counseling due to nightmares, anxiety, and fear associated with media violence.17 Another study of 3rd to 8th graders confirmed the relationship between trauma symptoms (such as nightmares) and increased television viewing.18 After the events of September 11, 2001, many Americans developed symptoms of post-traumatic stress disorder (PTSD). One study determined that increased television viewing for the few days after the event was a stronger predictor of PTSD than living in New York City, having had a friend or relative involved in the event, or even having actually been inside the World Trade Center that day.19 The Cost of Media Violence in the United States and Worldwide In spite of the wealth of data connecting media and actual violence, the extent of damage on our society remains in question. One researcher explored epidemiologically the introduction of television into various societies. He found that the homicide rate consistently doubled in different societies (United States, Canada, and South Africa) during the 10-15 year period after the introduction of television, whenever that happened to be. He extrapolated that, had TV never been introduced, each year the United States would have 10,000 fewer homicides, 70,000 fewer rapes, and 700,000 fewer injurious assaults.20 With American media quickly spreading across the world, the problem has become global. Researchers believe that, as of 1993, media violence was responsible for about 5-15 percent of total actual world violence.21 Other Media Although most research on media violence has involved television and film, other types of media violence likely contribute to societal violence as well. Violent video games have been shown to increase aggression and delinquency.22 The two youths responsible for the killings in Littleton, CO avidly played Doom, a violent video game used to train soldiers to kill. They created a customized version of the game involving two shooters with unlimited ammunition, extra weapons, and defenseless victims—a fantasy which they later brought to reality in their high school.22 More research needs to be done on the potential of computerized video games, the Internet, and other media to increase violence. Future Directions Limiting exposure is one method of lessening the impact of violent media on youth. This can be achieved informally or through the use of technology which “locks out” certain channels or amounts of television. This does not, however, affect the amount of film violence or other types of media violence consumed. Although film ratings and advisory labels can help parents decide on programs to be avoided, there are two major problems with relying on this system. First, certain labels, such as “parental discretion advised” and “R” have been shown to attract children, especially boys.8 Second, as has been noted, violence is present is many programs not considered to be violent, such as children’s cartoons. In addition to limiting exposure to violent media, educational efforts should be developed to help children understand the divide between real and fictionalized violence. Such media literacy programs have been shown to be effective, both in limiting the negative effects of media as well as in exploring the potential positive and pro-social uses of media.23-26 Families should limit and monitor media consumption. Children under 2 years of age should be discouraged from watching television. Before this age, direct social interaction is critical to brain development, and television has been shown to interfere with such interaction.23 Other children and adults should limit media consumption to less than an average of 1-2 hours a day. Adults should monitor the various media to which their children are exposed, including TV, films, video games, music videos, and the Internet. Age-Appropriate Techniques for Childhood Discipline Intervention Infant Toddler School-age Adolescent Positive reinforcement + + + + Redirecting + + + 0 Verbal instruction/explanation 0 Ltd + + Time-out 0 + + 0 Establishment of rules 0 0 + + Grounding 0 0 + + Withholding privileges 0 0 + + 0 = Little or no effectiveness; + = effective/recommended; Ltd = limited, may work in certain situations or with more mature toddlers. Positive Reinforcement Positive reinforcement is crucial to discipline. One of the most powerful forms of positive reinforcement is parental attention, which should focus on good behavior rather than undesirable behavior. Unfortunately, undesirable behavior more frequently gains parental attention.1 Parents must identify appropriate behaviors and give frequent feedback, rewarding good behavior immediately so that the child can associate the reward with the good behavior.7 Rewards can range from smiles, words of praise, and other signs of affection to special activities, extra privileges, and material items.5 A token economy system is effective with many children. In this technique, the child earns rewards (such as stars) for desired behaviors and loses the rewards for undesirable behavior. The rewards can be cashed in for prizes after a specified time.11 Punishment Punishment is sometimes a necessary element of discipline, but to be an effective tool it must be coupled with rewards for good behavior. Punishment should be used for teaching, not for revenge. Parents should not punish accidents or behaviors that are part of normal development (such as thumb-sucking or toilet-training accidents in toddlers), and they should avoid teasing, shaming, or nagging.5 Extinction “Extinction” is a form of discipline that eliminates inadvertent positive reinforcement for unacceptable behavior.1 Ignoring the behavior of toddlers who whine or have tantrums eliminates the positive reinforcement of a response to that behavior. “Time-out” is the most commonly practiced (and often badly managed) form of extinction. Time-out must involve removing the child from the problem situation. The child should be sent to a corner or instructed to sit in a room with no toys or television. The environment should be neutral, boring, non-frightening, and safe. Time-out works well for children from 18 months up to five or six years of age, and it is particularly useful for the correction of temper tantrums, whining, yelling, fighting, and aggression.5 Effective time-out requires that the child be ignored, and the session should end only when the child has been calm and quiet for at least 15 seconds.3,12 Time-out should last for a specified time, usually one minute per year of life (to a maximum of five minutes) without interaction.1,3 Time-out works best if the child receives regular attention (“time-in”) otherwise. The child must appreciate the change from the routine, and the contrast is critical. If a parent claims that time-out does not work, the physician should ask how the parent spends time-in.12 Time-out is rarely effective immediately but is highly effective over the long term. The most common reason for failure of time-out is the parents' inability to cope with their own distress and to ignore the child's pleading and bargaining.1 Withholding privileges is another form of extinction that is more appropriate for older children and adolescents. It requires the removal of a valued privilege, such as television viewing or visits with friends.1,5 This technique works best if it is used infrequently. Verbal Punishment Scolding expresses disapproval, with the intention of eliminating a behavior. This method can be transiently effective if used sparingly; however, when used frequently it can provoke anxiety and encourage the child to ignore the parent. It also may reinforce undesirable behavior by providing attention to the child.1 Verbal disapproval, when used alone, has been shown to increase noncompliance, and shouted commands often result in excitatory effects in preschoolers.3 Verbal punishment should never be used during time-out, since it reduces the effectiveness of time-out. Corporal Punishment Corporal punishment remains a common but controversial form of discipline. Corporal punishment involves inflicting physical pain, usually in the form of spanking. Acceptable spanking has been limited traditionally to the use of an open hand on the buttocks or extremity with the intention of modifying behavior without causing injury.1 More than 90 percent of American families use spanking as a form of discipline for toddlers and, according to the National Family Violence Surveys, more than one half use spanking during the early teens.13,14 Corporal punishment is used more frequently in boys than in girls, especially in impoverished families. Other studies confirm harsher discipline practices among low-income parents, particularly those who experience more family stress.15 Physical punishment is also common among socioeconomically mid-level, intact, well-educated families. One study16 has shown that among this group, only 17 percent of families claim to have never used physical punishment, and 25 percent use it more than a few times weekly. Although spanking may be effective initially because of its shock value, it is less effective over the long term than extinction and becomes less effective with each use, sometimes even leading to escalation of punishment.1 Spanking also loses its effectiveness if it is characterized by rage or if signs of rejecting the child follow it.4 Spanking is inappropriate in children younger than 18 months, because they are too young to appreciate the connection between the behavior and the punishment. Furthermore, corporal punishment used in very young children has a greater likelihood of physical injury.1 At no time is it acceptable to strike a child with an object, use enough force to leave marks, pull hair, jerk arms, or shake a child. Physical punishment delivered in anger with the intent to cause pain is never appropriate.1 The distinction between corporal punishment and child abuse may be subjective, but the identification of abuse is important. Opponents of corporal punishment argue that frequent physical punishment interferes with the teaching of nonviolent modes of conflict resolution.13 Because spanking models aggressive behavior and inflicts pain, it may teach the lesson that, in some situations, it is acceptable to inflict pain on others.1,17 Studies have shown an association between corporal punishment received as a child and anger that persists into adulthood, increasing the likelihood that those persons will use physical punishment with their own children or physically assault a partner.13 The use of spanking in older children is associated with higher rates of childhood physical aggression, substance abuse, crime, and violence, and it has been linked to poor self-esteem, depression, and low educational achievement.13,14 Harsh discipline has also resulted in lowered intelligence among low-birth-weight girls.18 Despite the potential negative effects of corporal punishment, it is still widely accepted. One report19 indicates that 19 percent of mothers believe it is acceptable to spank a child who is less than one year old, and 74 percent believe it is appropriate to spank children one to three years of age. Among physicians, 59 percent of pediatricians and 70 percent of family physicians support the use of corporal punishment, although approval is greatest when it is used to correct dangerous behavior.20

--- end discipline ---
- AAP recommends routine autism screening at ages 18 and 24 months.
Autism screening tool .mchat

1. Does your child enjoy being swung, bounced on your knee, etc.? {yes no:314532:o}

2. Does your child take an interest in other children? {yes no:314532:o}

3. Does your child like climbing on things, such as up stairs? {yes no:314532:o}

4. Does your child enjoy playing peek-a-boo/hide-and-seek? {yes no:314532:o}

5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or {yes no:314532:o}

pretend other things?

6. Does your child ever use his/her index finger to point, to ask for something? {yes no:314532:o}

7. Does your child ever use his/her index finger to point, to indicate interest in something? {yes no:314532:o}

8. Can your child play properly with small toys (e.g. cars or blocks) without just

mouthing, fiddling, or dropping them? {yes no:314532:o}

9. Does your child ever bring objects over to you (parent) to show you something? {yes no:314532:o}

10. Does your child look you in the eye for more than a second or two? {yes no:314532:o}

11. Does your child ever seem oversensitive to noise? (e.g., plugging ears) {yes no:314532:o}

12. Does your child smile in response to your face or your smile? {yes no:314532:o}

13. Does your child imitate you? (e.g., you make a face-will your child imitate it?) {yes no:314532:o}

14. Does your child respond to his/her name when you call? {yes no:314532:o}

15. If you point at a toy across the room, does your child look at it? {yes no:314532:o}

16. Does your child walk? {yes no:314532:o}

17. Does your child look at things you are looking at? {yes no:314532:o}

18. Does your child make unusual finger movements near his/her face? {yes no:314532:o}

19. Does your child try to attract your attention to his/her own activity? {yes no:314532:o}

20. Have you ever wondered if your child is deaf? {yes no:314532:o}

21. Does your child understand what people say? {yes no:314532:o}

22. Does your child sometimes stare at nothing or wander with no purpose? {yes no:314532:o}

23. Does your child look at your face to check your reaction when faced with

something unfamiliar?{yes no:314532:o}

Children who fail more than 3 items total or 2 critical items (particularly if these scores remain elevated after the follow-up interview) should be referred for diagnostic evaluation by a specialist trained to evaluate ASD in very young children. In addition, children for whom there are physician, parent, or other professional’s concerns about ASD should be referred for evaluation, given that it is unlikely for any screening instrument to have 100% sensitivity.

A child fails the checklist when 2 or more critical items are failed OR when any three

items are failed. Yes/no answers convert to pass/fail responses. Below are listed the failed

responses for each item on the M-CHAT. Bold capitalized items are CRITICAL items.

Not all children who fail the checklist will meet criteria for a diagnosis on the autism

spectrum. However, children who fail the checklist should be evaluated in more depth by

the physician or referred for a developmental evaluation with a specialist.

1. No 6. No 11. Yes 16. No 21. No

2. NO 7. NO 12. No 17. No 22. Yes

3. No 8. No 13. NO 18. Yes 23. No

4. No 9. NO 14. NO 19. No

5. No 10. No 15. NO 20. Yes

Heroin Resources in Northern Ky:

1 year old check (create .mscwell1yo
- screen for anemia REF

Preventitive visit algorithm attached below. Incorporate here and make a smart phrase. 

.cj - psychiatry H&P.

- enter these to meet meaningful use criteria for obesity and asthma
- see this emai 

- G- rods of urinary and GI tracts (including pseudomonas), Neisseria, some G+ (w) A.B. Bayer
- GI upset, rash, HA, dizziness, cartilage damage.
- Bacteriocidal, Inhibits DNA gyrase (topoisomerase II), don't take with ant-acids.
- Use levofloxacin in CAP because cipro has little activity against Strep pneumo.

- Piperacillin/Tazobactam (inhibits B-lactamases) (Wyeth)
- G+ & G- including anaerobes (incl pseudomonas).
- Preferred for P. aeruginosa CAP
- Good for SBP prophylaxis, PNA, peritonitis, diabetic foot infections.
- Bacteriocidal, bind PBPs, Blocks X-linking of cell wall, activate autolytic enzymes.

- HEN PEcKs + 4th generation ceph w/ increased activity against ps and G+
- Bacteriocidal, inhibit cell wall synthesis
- Hypersensitivity reactions, x-hypersensitivity with penicillins 5-10%

- URIs, PNAs, STD, strep (pts allergic to pen), mycoplasma, legionella, chlamydia, neisseria
- prolonged QT (esp ery), GI discomfort, acute cholestatic hepatitis, eosinophilia, skin rash.
- increases serum theophyllines, oral anticoagulants
- binds 30s r subunit

- BNP correlates with left ventricular end diastolic pressure.
  This in turn correlates with dyspnea and CHF.
  Review recent echos and end diastolic pressures to correlate.
  BNP is cleared by the kidneys and levels are inversely related to Creatinine clearance.

GU examination

 Sexual development and secondary sexual characteristics appropriate. The testicles are descended bilaterally The left and right testicles are firm and without masses, lesions or tenderness. There are no penile lesions or discharge from the urethra. The scrotum is without induration, erythema or edema. Hernias were not palpated in the inguinal canals. No hydrocele or varicocele appreciated.Cremasteric reflex intact BL. Negative Prehn's sign.

Opiod Consent Contracts
These are the smartlinks from Children's Hospital.

.RISRLT.. (Radiology findings)
.CURRENT - scheduled physicas on on admission
.ActiveIP - active inpatient medications
.IPVITALS - past 24 hours
.FPHANDP - Family Practice H&P Dot Phrase
.EDLABS - Emergency Department Labs


Shoulder Examination Redacted From:
Neer's sign:

    Shoulder Examination

1. Inspection
2. Palpation
3. ROM
4. Strength
5. Special Tests

1. Inspection
Gross abnormality
Swelling of AC joint
Bilateral Asymmetry
Muscle atrophy esp. of the Supraspinatus, Infraspinatus or Deltoid

2. Palpation
1. Sternoclavicular joint noting any pain
2. Clavicle
3. AC joint (look for the soft spot just posterior to the end of the clavicle)
4. Acromion
5. Subacromial bursa
6. Bicipital groove (anterior superior humoral head)
7. Greater tuberosity which is just anterior to the lateral border of the acromion.
8. Spine of the scapula
9. Supraspinatus
0. Infraspinatus

3. ROM
1. Forward Flexion to 180 degrees (A-Men)
2. Extension to 40 degrees posterior (A-Bird)
3. Abduction from 0 to 180 degrees
4. Abduction of arms down at the sides back to 0 degrees.
5. External rotation with arms at sides and flexed 90 degrees to about 45 deg.
-- Apply scratch test to superior medical aspect of opposite scapula
6. Internal rotation to 65 deg.
-- Reach both hands up the back as far as possible (use inf. border of opp. scapula T7)

4. Strength
1. Flexion
2. Extension
3. External Rotation (Infraspinatus and Teres Minor)
4. Internal Rotation to test subscularis.
5. Jobes test with arms out and thumbs down (dump cans) have pt push up against your hands.
6. Subscularis with Lift Off Test

5. Special Tests for Rotator cuff, Impingement problems, Biceps tendon Labial tears Shoulder Instability
1. Drop Arm test for rotator cuff test (specifically the supraspinatus). Pt will not be able to hold shoulder at 90 degree and it will drop to her side.
2. Impingement tests of the area under the acromioclavicular joint that rotator muscles travers
-- Neer's sign Stabilze scapula, Pronate the affected arm, Passively forward flex the arm as high as possible, this pinches the rotator cuff muscles under the coracoacromial arch.  A positive test is any pain reported by the patient.
-- Hawkins test is performed by forward-flexing the patient's arm to 90 degrees, bending the elbow and then forcibly internally rotating the humerus.  This drives the greater tuberosity  under the coracoacromial arch impinging the supraspinatus tendon.
-- Steves test iw performed by have the patient forward flex her arm against residence with the palm supinated pain indicates biceps tendon or labral pathology.
-- Obrien's test which is a more sensitive test for labral tears. Forward flex the patient's arm to 90 degrees then adduct it 20 degrees and internally rotate it so that the thumb is down. Ask the patient to resist the downward pressure. Next, externally rotate the arm so that the thumb is up and ask to patient to resist downward pressure. A positive test is pain or painful clicking which occurs when the patient's thumb is down and then is somewhat relieved when the patient's thumb is back up.
-- Crank test for labral pathology by abducting the patient arm in scapular plane, flexing the elbow, and applying a gentle axial load to the glenohumoral joint while internally and externally rotating the humerus. A postive test is pain, catching or painful clicking.
-- Apprehension test for glenohumoral joint stability which can be performed with the patient standing or sitting. With one had stabilize the scapula then rotate the arm into 90 degrees abduction then externally rotate the humerus. A positive test is a look of apprehension on the patient's face. The relocation test is applied after a positive apprehension test by applying posterior pressure on the proximal humerus and noting the patient's sense of relief. The anterior relief test for anterior shoulder instability can be performed with the patient in the same position  as for the relo test. A positive test is the report of pain or a feeling of instability on release of pressure from the proximal humerus.

First Version for Smart Phrase redacted from the above.

Shoulder Examination


Palpation: Digital examination of bony landmarks including the acromioclavicular joints, the medial and lateral heads of the clavicles,

Range of motion: Strength: 5/5 in the shoulder and upper extremities bilaterally with symmetrically equal strength on internal and external rotation, abduction and adduction of the upper extremities and shoulders.

No gross abnormality
No assymmetry of the upper extremeities or torso. 
No deformity, no rash, no bruising.
No sign of muscular atrophy of the supraspinatus, infraspinatus or deltoid.
No trauma.
No swelling of the AC joint.
No erythema.

Palpation - for tenderness, swelling, irregularity.
None - sternoclavicular joint.
None - clavicle.
None - AC joint.
None - acromion tenderness.
None - subacromial bursa.
None - bicipital groove (anterior superior humoral head)
None - greater tuberosity (just anterior to the lateral border of the acromion).
None - spine of the scapula.
None- supraspinatus.
None - infraspinatus.

ROM - Symmetric bilaterally with no limitations. 
Patient felt initially that he could not raise the left arm above the level of the shoulder on abduction, however subsequent testing did not reveal limitation to motion or remarkable tenderness.
Yes - Forward Flexion to 180 degrees (A-Men)
Yes - Extension to 40 degrees posterior (A-Bird)
Yes - Abduction from 0 to 180 degrees
Yes - Abduction of arms down at the sides back to 0 degrees.
Yes - External rotation with arms at sides and flexed 90 degrees to about 45 deg.
          -- Appled 'scratch test' to superior medical aspect of opposite scapula
Yes - Internal rotation to 65 deg.
         -- Could reach both hands up the back as far as possible (usually inf. border of opposite scapula is at approximately T7)

5/5 - Flexion
5/5 - Extension
5/5 - External Rotation (Infraspinatus and Teres Minor)
5/5 - Internal Rotation to test subscularis.
5/5 - Jobes test with arms out and thumbs down (dump cans) have pt push up against your hands.
5/5 - Subscularis with Lift Off Test

Special Tests for Rotator cuff for  Impingement, biceps tendon labial tears and shoulder instability
Neg Drop Arm test for rotator cuff test (specifically the supraspinatus). Pt will not be able to hold shoulder at 90 degree and it will drop to the side.
Neg Impingement tests of the area under the acromioclavicular joint that rotator muscles travers
Neg Hawkins test is - forward-flex arm to 90 degrees, bend elbow, forcibly internally rotate the humerus.  Drives the greater tuberosity  under the coracoacromial arch impinging the supraspinatus tendon.
Neg Steves test iw performed by have the patient forward flex her arm against residence with the palm supinated pain indicates biceps tendon or labral pathology.
Obrien's test for labral tears. Forward flex the patient's arm to 90 degrees then adduct it 20 degrees and internally rotate it so that the thumb is down. Ask the patient to resist the downward pressure. Next, externally rotate the arm so that the thumb is up and ask to patient to resist downward pressure. A positive test is pain or painful clicking which occurs when the patient's thumb is down and then is somewhat relieved when the patient's thumb is back up.
Neg Crank test for labral pathology by abducting the patient arm in scapular plane, flexing the elbow, and applying a gentle axial load to the glenohumoral joint while internally and externally rotating the humerus. A postive test is pain, catching or painful clicking.
-- Apprehension test for glenohumoral joint stability which can be performed with the patient standing or sitting. With one had stabilize the scapula then rotate the arm into 90 degrees abduction then externally rotate the humerus. A positive test is a look of apprehension on the patient's face. The relocation test is applied after a positive apprehension test by applying posterior pressure on the proximal humerus and noting the patient's sense of relief. The anterior relief test for anterior shoulder instability can be performed with the patient in the same position  as for the relo test. A positive test is the report of pain or a feeling of instability on release of pressure from the proximal humerus.
Mental Status Examination
The patient is alert and oriented in all spheres.
Appearance is consistent with the stated age.
The thought process is logical and sequential.
Thought content: Denies suicidal or homicidal ideation, hallucinations, delusions or paranoia. 
Patient is pleasant, cooperative and appears motivated for treatment.
Intellectual functioning appears overall intact.
Memory is good for immediate, recent and remote.
 Acute Pancreatitis:

Acute Pancreatitis: SIRS 0/4, VSSAF. Given the drinking history and presentation along with the Lipase level of 461 acute pancreatitis is likely. Would expect a return to normal in 7-14 days. Not hypocalcemic. AST/ALT 232/98 is also consistent with an alcohol-induced presentation as is the MCV of 98.9 and Mg of 1.4. Her albumin level at 4.9 is not consistent with the poor nutritional status often seen among alcoholics. BGL is 105 which is concerning for decreased pancreatic function or insulin resistance. Gall stone pancreatitis is also in the differential and would support the total bilirubin level of 2.5. Alkaline phosphatase was 97 which does not support an obstructive picture, however. An ultrasound was performed on 7/31/12 and called as normal RUQ. RUQ ordered. Acute cholecystitis and perforated ulcer are further down on the list. RUQ is ordered. There is no history of ulcer disease in this patient. Alcoholic gastritis is likely and appears to have been in part or repsonsilbe for previous presentations of N/V and emesis last year. CT obtained on 10.9.12 for emesis was called as unremarkable.

- Abdominal CT

- Activity as tolerated.

- Vital signs per routine.

- Telemetry monitoring

- Strict intake and output

- Weigh patient

- BMP, CBC qam

- Morphine 1-2 mg Q4H PRN pain

- NS 1 liter bolus + 250 ml/hr.

- Urine drug screen

- HBA1c

- Acute hepatitis panel


- CIWA protocol.

- thiamine B1 injection 100 mg X 1

- Theragran tablet 1 mg, folic acid 1mg, thamine 100 mg daily (Rally pack)

- Social work consulted - requested inpatient treatment at Falmouth or similar if possible.

- Discussed with patient at length the risks of pancreatitis and alcoholism and need for AA / group support follow up.


- Continue levothyroxine 100 mcg daily.


Pill esophagitis:

- Protonix while IP, continue omeprazole OP.

- CT scan

- Stool hemoccult.

FEN/PPX: NPO, Protonix 40 mg daily, Zofran 4 mg Q4H, folic acid, MVI, thamine (B1), Mg sulfate, NS bolus in ER followed by 250 ml/hr continuous, ambulation for DVT prophylaxis.

Health Maintenance: Flu vaccination, pneumococcal vaccine.

Code status: Full

DISPO: Admit for to TCU for monitoring and treatment of acute pancreatitis.


Marc Curvin,
Jun 17, 2013, 8:50 AM
Marc Curvin,
Mar 25, 2013, 7:11 AM
Marc Curvin,
Mar 22, 2013, 8:39 AM