Verhaltens- und fertigkeitenbasierte Frühinterventionen bei Kindern mit Autismus

Einleitung: Zu den autistischen Syndromen werden der frühkindliche Autismus (Kanner-Syndrom), das Asperger-Syndrom und atypische Autismusformen oder nicht-spezifizierte tiefgreifende Entwicklungsstörungen gezählt. Bei den autistischen Syndromen liegen Beeinträchtigungen (1) der Kommunikation und (2) der sozialen Interaktion vor. Weiterhin weisen (3) die Kinder in unterschiedlichem Maß stereotypes, repetitives Verhalten auf und haben bestimmte Sonderinteressen. Verhaltensbasierte Frühinterventionen bei Kindern mit Autismus basieren auf lerntheoretischen und verhaltenstherapeutischen Konzepten. Sie berücksichtigen die besonderen vorliegenden Beeinträchtigungen in der Wahrnehmung, der emotionalen Reaktionen, der sozialen Interaktionen sowie der Kommunikationsmuster. Die systematische Anwendung und Evaluation solcher Modelle in Deutschland ist aber bisher eher die Ausnahme. Fragestellungen: - Wie sind die gesundheitliche Effektivität und Sicherheit von verhaltens- oder fertigkeitenbasierten Frühinterventionen bei autistischen Syndromen untereinander und verglichen mit einer Standardbehandlung? - Gibt es Hinweise auf besondere Wirkfaktoren für die Effektivität? - Wie ist die Kosten-Effektivität? - Wie hoch sind die Kosten der verschiedenen Interventionen? - Lassen sich aus ethischen und rechtlichen Überlegungen Schlüsse für die Anwendung der betrachteten Interventionen bei Betroffenen mit autistischem Syndrom in der Praxis ziehen? Methoden: Basierend auf einer systematischen Literaturrecherche werden ab 2000 in deutscher oder englischer Sprache veröffentlichte kontrollierte Studien zu verhaltens- oder fertigkeitenbasierten Frühinterventionen bei Kindern mit Autismus im Alter von bis zu zwölf Jahren eingeschlossen und bewertet. Die Mindestzahl an Studienteilnehmern muss zehn pro Interventionsgruppe betragen. Ergebnisse: Insgesamt 15 Veröffentlichungen klinischer Primärstudien, acht systematische Reviews und eine ökonomische Veröffentlichung erfüllen die Einschlusskriterien. Die meisten Studien evaluieren intensive Frühinterventionen, die sich an das Modell von Lovaas (Early intensive behavioural treatment (EIBT), Applied behavioural analysis (ABA)) anlehnen. Einige Studien evaluieren andere Interventionen, die teilweise pragmatisch waren und teilweise einem bestimmten Modell folgen (spezifisches Elterntraining, Responsive education and prelinguistic milieu teaching (RPMT), Joint attention (JA) und symbolisches Spielen (SP), Picture exchange communication system (PECS)). Verhaltensanalytische Interventionen basierend auf dem Lovaas-Modell können weiterhin als die am besten empirisch abgesicherten Frühinterventionen angesehen werden. Vorschulkinder mit Autismus können durch verhaltensbasierte Interventionen mit einer Mindestintensität von 20 Stunden pro Woche Verbesserungen in kognitiven und funktionalen Bereichen (expressive Sprache, Sprachverständnis und Kommunikation) erreichen. Es bleibt jedoch unklar, welche Mindestintensität notwendig ist, und welche Wirkkomponenten für die Ergebnisse verantwortlich sind. Für andere umfassende Frühinterventionen bei Kindern mit Autismus liegt keine hochwertige Evidenz vor. Die für den ökonomischen Teilbereich identifizierte und einbezogene Publikation ist methodisch und thematisch nicht dazu geeignet, die Fragen nach der Kosten-Effektivität oder den Kostenwirkungen von Frühinterventionen beim Autismus auch nur ansatzweise zu beantworten. Publikationen zu rechtlichen, ethischen oder sozialen Aspekten werden nicht identifiziert. Die finanzielle Lage der Betroffenen und der Familien wird durch das Pflege-Weiterentwicklungsgesetz (Pf-WG) verbessert. Weitere rechtliche Belange betreffen die Betreuung und die Deliktfähigkeit der Menschen mit Autismus. Auch die gleichheitliche Betreuung und Versorgung sind insbesondere vor dem Hintergrund der Pflege im häuslichen Umfeld eine wichtige Frage. Diskussion: Es gibt nur wenige methodisch angemessene Studien zur Beurteilung der Wirksamkeit von Frühinterventionen bei Kindern mit Autismus. Die meisten Studien sind vergleichsweise kurz und haben teilsweise kein verblindetes Ergebnis-Rating. Der Mangel an hochwertigen vergleichenden Studien lässt keine solide Antwort auf die Frage zu, welche Frühintervention bei welchen Kindern mit Autismus am wirksamsten ist. Programme nach dem Lovaas-Modell scheinen am wirkungsvollsten zu sein. Dies gilt vor allem, wenn sie klinikbasiert durchgeführt werden. Zu einzelnen Wirkfaktoren von Frühinterventionen nach dem ABA-Modell konnte allerdings keine solide Evidenz gefunden werden. Es zeigte sich, dass ein Elterntraining hinsichtlich der Verbesserung der Kommunikation besser ist als eine Routinebehandlung, in der eine Mischung von Theapieelementen angewendet wird. Sowohl für die klinischen als auch die gesundheitsökonomischen Studien besteht das Problem unzureichender Verallgemeinerbarkeit der Studienergebnisse in den deutschen Versorgungskontext. Die ökonomischen Studien sind methodisch und thematisch nicht dazu geeignet die aufgeworfenen Fragestellungen zu beantworten. Schlussfolgerung: Basierend auf der derzeitigen Studienlage liegt für keine der untersuchten verhaltensbasierten Frühinterventionen bei Kindern mit Autismus ausreichende Evidenz vor. Die in diesem Bericht ausgewerteten Studien und Reviews legen nahe, dass Vorschulkinder mit Autismus durch verhaltensbasierte Interventionen mit einer Mindestintensität von 20 Stunden pro Woche Verbesserungen in kognitiven und funktionalen Bereichen erreichen können. Es gibt bisher keine Hinweise, dass bei einem substantiellen Anteil der Kinder eine vollständige Normalisierung der Entwicklung erreicht werden kann. Die meiste Evidenz liegt für die ABA vor. Ein Minimum an erforderlicher oder sinnvoller Behandlungsintensität kann jedoch nicht angegeben werden. Eine professionelle Umsetzung eines verhaltensbasierten Frühinterventionsprogrammes in engem und ausführlichem Kontakt mit den Kindern und unter Einbeziehung der Eltern erscheint sinnvoll. Zur Kosten-Effektivität von intensiven Frühinterventionen bei Kindern mit Autismus können keine validen Angaben gemacht werden. Effektive Frühinterventionen könnten jedoch die Gesamtkosten des Autismus langfristig reduzieren, indem die anfallenden hohen Aufwendungen durch eine spätere bessere soziale Anpassung überkompensiert werden.

A quantitative application of symbolic interactionism to advance directive completion by older adults

This study examined contextual and situational influences on older adults' decision to complete advance directives by means of a conceptual framework derived from symbolic interactionist theory and a cross-sectional, correlational research design. It was hypothesized that completion of advance directives among older adults would be associated with visiting or participating in the care of a terminally ill or permanently incompetent individual sustained by technology. Using a 53-item questionnaire, computer assisted telephone interviews (CATI) were conducted with 398 community dwelling adults between September and October 2003. Respondents were contacted using random-select dialing from a listed sample of 99% of household telephone numbers in one South Florida census tract. Over 90% of households in this tract include an individual age 65 or older. ^ The results revealed that contrary to most reports in the literature a substantial proportion of older adults (82%) had completed advance directives and that the link between older adults and document completion was mainly through attorneys and not mandated agents, health care professionals. Further, more than one third of older adults reported that religion/spirituality was not an important part of their life, suggesting that the recommended practice of offering religious/spiritual counseling to all those approaching death be reexamined. The hypothesis was not supported (p > .05) and is explained by the situational emphasis on the variables rather than on structural influences. In logistic regression analysis, only increasing age (p = .001) and higher education (p = < .001) were significant but explained only 10% of the variance in document completion. ^ Based on the findings, increased interdisciplinary collaboration is suggested with regard to the advance directive agenda. Since attorneys play a key role in document completion, other professions should seek their expertise and collaboration. In addition, the inclusion of a religious/spiritual preference section in all living wills should be considered as an essential part of a holistic and individually appropriate document. Implications for social work education, practice, and advocacy are discussed as well as suggestions for further research. ^

Original sin: divine and symbolic violence in the turn to the Apostle Paul

When we take a step back from the imposing figure of physical violence, it becomes possible to examine other structurally violent forces that constantly shape our cultural and political landscapes. One of the driving interests in the “turn to Paul” in recent continental philosophy stems from wrestling with questions about the real nature of contemporary violence. Paul is positioned as a thinker whose messianic experience began to cut through the violent masquerade of the existing order. The crucifixion and resurrection of the Messiah (a slave and a God co-existing in one body) exposed the empty grounding upon which power resided. The Christ-event signifies a moment of violent interruption in the existing order which Paul enjoins the Gentiles to participate in through a dedication of love for the neighbour. This divine violence aims to reveal and subvert the “powers,” epitomised in the Roman Empire, in order to fulfil the labour of the Messianic now-time which had arrived. The impetus behind this research comes from a typically enigmatic and provocative section of text by the Slovene philosopher, cultural critic, and Christian atheist Slavoj Žižek. He claims that 'the notion of love should be given here all its Paulinian weight: the domain of pure violence… is the domain of love' (2008a, 173). In this move he links Paul’s idea of love to that of Walter Benjamin’s divine violence; the sublime and the cataclysmic come together in this seemingly perverse notion. At stake here is the way in which uncovering violent forces in the “zero-level” of our narrative worldviews aids the diagnosis of contemporary political and ethical issues. It is not enough to imagine Paul’s encounter with the Christ-event as non-violent. This Jewish apocalyptic movement was engaged in a violent struggle within an existing order that God’s wrath will soon dismantle. Paul’s weak violence, inspired by his fidelity to the Christ-event, places all responsibility over creation in the role of the individual within the collective body. The centre piece of this re-imagined construction of the Pauline narrative comes in Romans 13: the violent dedication to love understood in the radical nature of the now-time. 3 This research examines the role that narratives play in the creation and diagnosis of these violent forces. In order to construct a new genealogy of violence in Christianity it is crucial to understand the role of the slave of Christ (the revolutionary messianic subject). This turn in the Symbolic is examined through creating a literary structure in which we can approach a radical Nietzschean shift in Pauline thought. The claim here, a claim which is also central to Paul’s letters, is that when the symbolic violence which manipulates our worldviews is undone by a divine violence, if even for a moment, new possibilities are created in the opening for a transvaluation of values. Through this we uncover the nature of original sin: the consequences of the interconnected reality of our actions. The role of literature is vital in the construction of this narrative; starting with Cormac McCarthy’s No Country for Old Men, and continuing through works such as Melville’s Bartleby the Scrivener, this thesis draws upon the power of literature in the shaping of our narrative worlds. Typical of the continental philosophy at the heart of this work, a diverse range of illustrations and inspirations from fiction is pulled into its narrative to reflect the symbolic universe that this work was forged through. What this work attempts to do is give this theory a greater grounding in Paul’s letters by demonstrating this radical kenotic power at the heart of the Christ-event. Romans 13 reveals, in a way that has not yet been picked up by Critchley, Žižek, and others, that Paul opposed the biopolitical power of the Roman Empire through the weak violence of love that is the labour of the slaves of Christ on the “now-time” that had arrived.

Pipkiiα Is Widely Expressed In Hematopoietic-derived Cells And May Play A Role In The Expression Of Alpha- And Gamma-globins In K562 Cells.

Characterized for the first time in erythrocytes, phosphatidylinositol phosphate kinases (PIP kinases) belong to a family of enzymes that generate various lipid messengers and participate in several cellular processes, including gene expression regulation. Recently, the PIPKIIα gene was found to be differentially expressed in reticulocytes from two siblings with hemoglobin H disease, suggesting a possible relationship between PIPKIIα and the production of globins. Here, we investigated PIPKIIα gene and protein expression and protein localization in hematopoietic-derived cells during their differentiation, and the effects of PIPKIIα silencing on K562 cells. PIPKIIα silencing resulted in an increase in α and γ globins and a decrease in the proliferation of K562 cells without affecting cell cycle progression and apoptosis. In conclusion, using a cell line model, we showed that PIPKIIα is widely expressed in hematopoietic-derived cells, is localized in their cytoplasm and nucleus, and is upregulated during erythroid differentiation. We also showed that PIPKIIα silencing can induce α and γ globin expression and decrease cell proliferation in K562 cells.

Historias infantis : o simbolismo, a ludicidade e a motricidade na ação da educação motora

Universidade Estadual de Campinas . Faculdade de Educação Física

Comportamentos lúdicos entre crianças do nordeste do Brasil: categorização de brincadeiras

Este artigo visa categorizar as brincadeiras das crianças de um povoado rural do nordeste do Brasil. Foram observadas individualmente 32 crianças entre dois e 12 anos, de ambos os sexos, brincando em ambiente livre, em sessões de cinco minutos. A categoria de 'brincadeiras simbólicas' foi a mais observada (49%). Os temas das brincadeiras simbólicas estavam predominantemente atrelados ao modo de vida local. Diferenças de gênero foram observadas e analisadas. Os dados sugerem que meninas brincam mais simbolicamente, enquanto as brincadeiras dos meninos são mais variadas. A relação entre brincadeira e contexto baseia-se no aproveitamento das potencialidades que o ambiente oferece para o desenvolvimento da criança caracterizando as relações entre aspectos particulares de cada ambiente e as atividades lúdicas desenvolvidas.

Prolactin May Not Play a Role in Primary Antiphospholipid (Hughes') Syndrome

The relationship between prolactin (PRL) and the immune system has been demonstrated in the last two decades and has opened new windows in the field of immunoendocrinology. However, there are scarce reports about PRL in primary antiphospholipid syndrome (pAPS). The objective of this study was to evaluate PRL levels in patients with pAPS compared to healthy controls and to investigate their possible clinical associations. Fifty-five pAPS patients according to Sapporo criteria were age- and sex-matched with 41 healthy subjects. Individuals with secondary causes of hyperprolactinemia (HPRL) were excluded; demographic, biometric, and clinical data, PRL levels, antiphospholipid antibodies, inflammatory markers, and other routine laboratory findings were analyzed. PRL levels were similar between pAPS and healthy controls (8.94 +/- 7.02 versus 8.71 +/- 6.73 ng/mL, P = .876). Nine percent of the pAPS patients and 12.1% of the control subjects presented HPRL (P = .740). Comparison between the pAPS patients with hyper- and normoprolactinemia revealed no significant differences related to anthropometrics, clinical manifestations, medications, smoking, and antiphospholipid antibodies (P > .05). This study showed that HPRL does not seem to play a role in clinical manifestations of the pAPS, differently from other autoimmune rheumatic diseases.

Physiological demands of match-play in elite tennis: A case study

The physiological and perceptual demands together with match notation of a four-set tennis match were studied in two elite professional players during the preparation for the 2008 Davis Cup. The design of this case report is unique in that it is the first to describe the demands of prolonged match-play (197 min) over four sets in ecologically valid conditions. The variables measured before and after each set included blood lactate and glucose concentrations, body mass, and perception of effort. Stroke count for each rally and heart rate were recorded during each set while salivary cortisol concentration was determined before and after the match. The rally length decreased as the match progressed. The results showed significant physiological stress, with each player losing greater than 2.5% of body mass (as fluid) and having elevated salivary cortisol concentrations after the match. Heart rate and perception of effort were also increased following each set indicating increasing stress. However, blood lactate decreased following the fourth set while blood glucose was maintained. The results also suggest that elite players may adjust work rates or tactics to cope with the increased perception of effort. This report shows that four sets of tennis are associated with increasing stress and fatigue.

Stromal cells play a role in cervical cancer progression mediated by MMP-2 protein

Metalloproteinases, especially metal loprotemase-2 (MMP-2), are known for their role in the degradation of the extracellular matrix. Nevertheless, a thorough understanding of MMP-2 expression in neoplastic lesions of the uterine cervix has yet to be accomplished. This study aimed to analyze the MMP-2 expression in cervical intraepithelial neoplasia III (CIN3) and in cervical squamous cell carcinoma, in tumor cells and adjacent stromal cells. MMP-2 expression was assessed by an immunohistochernical technique. MMP-2 expression was greater in the stromal cells of invasive carcinomas than in CIN3 (p < 0.0001). MMP-2 expression in stromal cells correlates with the clinical stage, gradually increasing as the tumor progresses (p = 0.04). This study corroborates that stromal cells play an important role in tumor invasion and progression, mediated by the progressive enhancement of MMP-2 expression from CIN3 to advanced invasive tumor. The intense MMP-2 expression most probably is associated with poor tumor prognosis.

Does Cyclophosphamide Play a Protective Role Against Neuronal Loss in Chronic T. cruzi Infection?

In this study, we verified the possible role of cyclophosphamide (CY) in protecting or not against neuronal losses in young and aged male Calomys callosus chronically infected with the MORC-1 strain of Trypanosoma cruzi through numerical quantification of neurons from the myenteric plexus of the colon and quantification of nitric-oxide concentration (NO) during the acute and chronic phase of infection. For this purpose, groups of young C. callosus were infected with the MORC-1 strain of T. cruzi. A group of infected animals received i.p. 0.2 mg/ml genuxal dissolved in distilled water treatment with CY. NO concentration in aged animals displayed reduced levels when compared to those found in young animals. No significant alterations in the number of neurons were observed in young animals, but for aged ones, a protective role of CY in reducing neuron loss was noted, in addition to enhancing the neuronal volume, area, and perimeter. These results suggest that CY administration, depending on the dose and time span, can act as a protective agent against neuronal losses.

Molecular cloning reveals that the p160 myb-binding protein is a novel, predominantly nucleolar protein which may play a role in transactivation by Myb

We have previously detected two related murine nuclear proteins, p160 and p67, that can bind to the leucine zipper motif within the negative regulatory domain of the Myb transcription factor. We now describe the molecular cloning of cDNA corresponding to murine p160. The P160 gene is located on mouse chromosome 11, and related sequences are found on chromosomes 1 and 12. The predicted p160 protein is novel, and in agreement with previous studies, we find that the corresponding 4.5-kb mRNA is ubiquitously expressed. We showed that p67 is an N-terminal fragment of p160 which is generated by proteolytic cleavage in certain cell types. The protein encoded by the cloned p160 cDNA and an engineered protein (p67*) comprising the amino-terminal region of p160 exhibit binding specificities for the Myb and Jun leucine zipper regions identical to those of endogenous p160 and p67, respectively. This implies that the Myb-binding site of p160 lies within the N-terminal 580 residues and that the Jun-binding site is C-terminal to this position. Moreover, we show that p67* but not p160 can inhibit transactivation by Myb. Unexpectedly, immunofluorescence studies show that p160 is localized predominantly in the nucleolus. The implications of these results for possible functions of p160 are discussed.

Monooxygenases play only a minor role in resistance to synthetic pyrethroids in the cattle tick, Boophilus microplus

We investigated the role of monooxygenases in resistance to synthetic pyrethroids (SPs) in the cattle tick, Boophilus microplus. We found that monooxygenases play only a minor role in resistance to SPs in both resistant and susceptible strains of B. microplus. We blocked the monooxygenases with piperonyl butoxide (PBO) and simultaneously applied the SPs, flumethrin and cypermethrin to larval B. microplus. PBO increased the effect of flumethrin (synergism ratios 2.7-8.9) more than it increased the effect of cypermethrin (synergism ratios 1.9-3.1). Of the four strains tested, Parkhurst, which is resistant to SPs, was the least affected by the addition of PBO (synergism ratios after cypermethrin was applied 1.9; after flumethrin 2.7) whereas N.R.F.S., the strain susceptible to SPs, was the most affected by synergism between PBO and SPs (synergism ratio after cypermethrin was applied 3.1; after flumethrin 8.9). We hypothesize that B. microplus lacks monooxygenases capable of conferring resistance to SPs because it and its recent ancestors were blood-feeders rather than herbivores.

An investigation of pretend play, mental state terms and false belief understanding: In search of a metarepresentational link

The aim of this study was to investigate the association between false belief comprehension, the exhibition of pretend play and the use of mental state terms in pre-school children. Ferry children, aged between 36 and 54 months were videotaped engaging in free play with each parent. The exhibit-ion of six distinct acts of pretend play and the expression of 16 mental sr:ate terms were coded during play. Each child was also administered a pantomime task and three standard false belief casks. Reliable associations were also found between false belief performance and the pretence categories of object substitution and role assignment, and the exhibition of imaginary object pantomimes. Moreover, the use of mental state terms was positively correlated with false belief and the pretence categories of object substitution, imaginary play and role assignment, and negatively correlated with the exhibition of body part object pantomimes. These findings indicate that the development of a mental state lexicon and some, bur not all, components of pretend play are dependent on the capacity for metarepresentational cognition.