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Gray, Larry A. MA; Msall, Emily R.; Msall, Michael E. MD
Sections of Developmental & Behavioral Pediatrics and Community Health Sciences, University of Chicago Comer Children's Hospital, Chicago, Illinois (Dr Gray and Ms Msall); and Institute of Molecular Pediatrics and Kennedy Center on Mental Retardation and the LaRabida Children's Hospital, Chicago, Illinois (Dr Msall).
Corresponding Author: Larry A. Gray, MD, Section of Developmental & Behavioral Pediatrics, University of Chicago Comer Children's Hospital, 950E 61st St, SSC Room 227, Chicago, IL 60637 (email@example.com).
The authors acknowledge Dr Peter Smith, Melissa Gray, CPNP, and the University of Chicago Early Intervention Team who provided feedback and a creative team approach to advocating for quality care pathways and family supports. This article is dedicated to Charley Blondis who taught all of us the value of being an optimal family member of a sister with genetic and autistic spectrum challenges. His untimely death highlighted the gaps between a culture of violence and a community of caring.
There is increasing public and healthcare provider awareness about the early signs and developmental challenges of children with autistic spectrum disorders (ASDs). Healthcare professionals are guided by several major policy statements regarding the diagnosis and management of autism. There remain substantial gaps between these guidelines and families' needs during the diagnostic process. This article provides a developmental and behavioral perspective for the professionals who desire to find guideposts in task of supporting families throughout the diagnostic process of autism. We illustrate the diversity of the ASDs using the International Classification of Functioning, Disability and Health Model and describe developmental and behavioral perspectives about the autism diagnostic process. Our overall goal is to enhance parent and professional collaboration in promoting the establishment of medical homes, accessing the highest quality developmental assessments, and implementing comprehensive supports for parents of children with ASDs.
THERE is increasing awareness about the early signs and developmental challenges of children with autistic spectrum disorders (ASDs) (Chakrabarti & Fombonne, 2001; Fombonne & Chakrabarti, 2001). Major policy statements by the American Academy of Pediatrics and the National Academy of Sciences have provided a template for widely disseminated state-of-the-art strategies for diagnosis and management (Committee on Children With Disabilities, 2001a; National Research Council Committee on Educational Interventions for Children With Autism, 2001). However, there remain substantial gaps between these guidelines and families' goals of feeling supported and accessing quality and comprehensive early childhood services (Anders & Gardner, 2003; Renty & Roeyers, 2006). The purpose of this article is to provide developmental and behavioral pediatric perspectives for healthcare professionals on ASDs with respect to communicating the developmental diagnosis, explaining medical advances to families, and providing ongoing family supports. We build on the International Classification of Functioning, Disability and Health (ICF) framework of enablement, functional assessment, and child and family well-being (World Health Organization, 2001). In approaching the developmental diagnosis of autism, we strive to begin a dialogue about the process of developmental diagnosis in the setting of a child's strengths and challenges while addressing the complex hopes, fears, stressors, and typical lack of family supports. In addition, we discuss some of the strengths of a developmental diagnostic approach that emphasizes a spectrum of outcomes and possibilities as well as some of the pitfalls of a categorical diagnosis, particularly when families in desperation try complementary interventions that may have adverse effects. Our goal is not to review the complexity of accepted and/or alternative treatments, as this has been recently done by the National Academy of Sciences (National Research Council Committee on Educational Interventions for Children With Autism, 2001) and Hyman and Levy (2005), but to highlight how the primary care provider positively impacts the diagnostic process and how ongoing family supports can be provided as families negotiate the complexity of management in the birth-to-3 and early preschool years. In this way, we begin to develop both problem-solving strategies and approaches essential to optimizing health, development, and functional competencies.
Major advances in pediatrics, child development, and developmental neurosciences have enhanced our understanding of children with autism (Bristol, McIlvane, & Alexander, 1998). These advances have included the prevention of neurodevelopmental sequelae in children with phenylketonuria (PKU). PKU is an inborn error of metabolism whereby children fed milk or natural proteins develop autism and developmental disabilities. Through specialized nutritional interventions, requiring both metabolic formulas and biochemical monitoring, children are severely restricted in their natural protein intake. Children with PKU cannot drink cow or soy milk or eat cookies, crackers, hamburgers, ice cream, pizza, cheese, hot dogs, cold cuts, or cake. The special protein formula provides the equivalent of a liver transplant and dialysis machine. In all 50 states, screening for PKU takes place in newborns whereby, after confirmatory biochemical analysis, a specialized biochemical formula is started.
Major progress in immunizations has led to the near elimination of congenital rubella, measles encephalitis, and Haemophilus influenzae meningitis and resulting postinfectious developmental disabilities including ASDs (Fombonne & Chakrabarti, 2001; Goldston, Gruenberg, & Lewis, 1986; Halsey, 2001; Halsey, Hyman, & Conference Writing Panel, 2001). Prior to these vaccines, substantial numbers of children developed intellectual disability as well as neurological disorders.
Neurodiagnostic advances have included the early detection of visual and hearing disorders, communicative and social developmental screening tools for evaluating parental initial concerns, and specific assessment scales for communication, play, social behaviors, and adaptive skills (Ozonoff, Rogers, & Hendren, 2003). Molecular genetic advances have included detection of fragile X syndrome, expanded banding karyotypes and FISH analysis for regional hot spots especially on chromosomes 15 and 7, and the genetic markers for the Rett syndrome and the tuberous sclerosis complex. The former is an X-linked dominant disorder whereby the MECP mutation impacts on a girl's ability to learn purposeful hand skills and communicative skills. The latter is an autosomal dominant neurogenetic syndrome with complex seizures, difficulty learning language, and social skills, and with more than half of the children meeting criteria for ASDs. Despite these molecular advances, most children with other neurodevelopmental disorders including autism cannot be given an exact etiologic explanation.
Research networks have been established by National Institutes of Child Health and Human Development and the Centers for Disease Control and Prevention to understand the epidemiology, genetic and environmental etiologies, and developmental processes involved in children with autism (Tager-Flusberg, Joseph, & Folstein, 2001). In addition, clinical research networks of multidisciplinary professionals and specialized university-affiliated centers of excellence have developed to explore advances in psychopharmacology, communicative and developmental interventions, and alternative medicine treatments (Arnold et al., 2000; Levy & Hyman, 2002; Rogers, 1998). This systemic collaboration offers the promise for scientific advances, but has not quieted several common misconceptions that exist regarding children with autism. Table 1 provides a list of some of the most frequent myths and the evidence-based reality that defines sources of family uncertainty.
There is also another major myth that there is an explosive epidemic of autism due to childhood immunizations (Nelson & Bauman, 2003; Murch et al., 2004; Offit & Jew, 2003). This leads to both suspicion of medicine and failure to understand that the preponderance of evidence supports the benefit of immunizations for the prevention of illness in children with autism and preventing both autism and severe disabilities in young children. For example, without rubella vaccine, the United States would experience epidemics of congenital rubella. Prior to this vaccine, as many as 11 000 fetal deaths and 2000 neonatal deaths occurred because of congenital rubella. In addition, more than 20 000 newborns were affected with the congenital rubella syndrome (Goldston et al., 1986). The sequelae of this syndrome include blindness in 10%, deafness in 50%, autism in 25%, as well as mental retardation, epilepsy, and cerebral palsy (Chess, 1978). Rubella vaccination prevents these epidemics. Prior to measles vaccine, significant numbers of children died from measles pneumonia and measles encephalitis. In 1923, more than 10 000 deaths were reported in 1 year because of measles. Between 1950 and 1962, almost 500 children per year died of measles (Goldston et al., 1986). In 1982, after a decade of immunization control efforts, there were 2 deaths. Approximately 1 in 1000 children with measles develops measles encephalitis and more than 50% have devastating long-term sequelae including autism (Benda, 1952). In an era where the promise of neuroscience has not yet brought new restorative treatments, immunizations are the best way to prevent both autism and other developmental disabilities.
The World Health Organization (2001) proposed a strengths- and supports-based model framework for describing individuals with disability. The ICF model describes a child's health and well-being in terms of 4 components: (1) body structures, (2) body functions, (3) activities, and (4) participation. Body structures are anatomical parts of the body, such as organs and limbs, as well as structures of the nervous, sensory, and musculoskeletal systems. Body functions are the physiological functions of body systems, such as digestion and respiration, and also include psychological functions such as attending, remembering, and thinking. Activities are tasks done by children, including learning, communicating, walking, carrying, feeding, dressing, toileting, and bathing. In older children, these tasks include reading, preparing meals, shopping, and washing clothes. Participation means involvement in community life, such as relationships with peers, going to school, and recreational activities.
The ICF model accounts for contextual factors in a child's life, including environmental and personal factors. Environmental factors include policy, social and physical facilitators and barriers, positive and negative attitudes of others, legal protections, and discriminatory practices. Personal factors include age, gender, interests, and sense of self-efficacy. A variety of preschool scenarios using the ICF model are illustrated in Table 2 for preschool children with ASD. These scenarios include a 1-year-old girl with infantile spasms secondary to tuberous sclerosis complex, 2-year-old boy who is nonverbal with autism, a 3-year-old girl with blindness and developmental regression, and a 4-year-old boy with fragile X syndrome, challenging behaviors, and autism. The ICF model explicitly measures functional strengths, social role activity, community participation, and environmental facilitators.
Over the past 50 years, autism has been diagnosed using different labels and criteria. We currently support the term "ASD" to encompass the formal categorical diagnoses of autistic disorder, pervasive developmental disorder—not otherwise specified (PDD-NOS), and Asperger's syndrome. Currently, the 2 standardized criteria for diagnosing these ASDs, DSM-IV and ICD-10, are similar (Volkmar & Pauls, 2003). Core diagnostic features include impairments in communication and social interaction coupled with restrictive and stereotyped patterns of behavior, interests, and activities. Onset is in the preschool years, with delays in language understanding and use, delays in joint attention and nonverbal skills, symbolic play difficulties (ie, pretend play), and difficulty with social interactions with parents and peers. Although current reviews mandate a medical evaluation for autism (Committee on Children With Disabilities, 2001b; Filipek et al., 2000), many children do not have an associated or causative medical condition (Fombonne, 1999). The medical differential diagnosis of autism includes global developmental delay, developmental language disorders (DLDs), and severe sensori-neural hearing impairments. There are also many rare neurogenetic disorders that impact on higher cortical functions including abstraction, problem solving, understanding viewpoints of others, information processing, and regulation of attention (eg, too short, too long, too inflexible) (Rapin, 1997). In addition, among a subset of children with language regression, a specific epilepsy pattern is present and called the Landau-Kleffner syndrome (Rapin & Katzman, 1998).
Some uncommon medical etiologies associated with autism include untreated PKU, tuberous sclerosis complex, retinopathy of prematurity, congenital cytomegalovirus infection, and fragile X, Lesch Nyhan, and Moebius syndromes. In addition, several genetic disorders such as Down, Prader-Willi, Angelman, and Williams syndromes and Duchenne muscular dystrophy have higher risks for ASDs. The lesson is not that all children with Down syndrome or Duchenne muscular dystrophy manifest behaviors consistent with ASD, but that among individuals with developmental and genetic vulnerability (ie, Down syndrome or Duchenne muscular dystrophy), higher rates of classical autism are found than the population prevalence of 1 to 2 per 1000 (Yeargin-Allsopp et al., 2003) and the ASD prevalence of 4 to 6 per 1000 (Szatmari, 2003; Yeargin-Allsopp et al., 2003).
There are improved tools for early recognition and increased awareness of the preschool presentation of children with ASDs. With expanded definitions of the autistic spectrum, there are more individuals who do not have the classical comorbidities of mental retardation/intellectual disability. By including Asperger's disorder in the autism spectrum, there is increased awareness of the social skill and motor coordination impairments that impact on school-aged children with learning disorders. Lastly, including preschool children with challenging behaviors and communicative and attention disorders as children with autistic spectrum disorder (PDD-NOS) substantially increases the number of children eligible for accommodations (504 Plans) and special education services (individualized education programs). Thus, to understand the changing epidemiology of preschool communicative, developmental, and neurobehavioral disorders, one must understand the background prevalence of communicative and cognitive disorders in early childhood.
Communicative impairments associated with developmental disabilities can be classified in terms of severity (high, low) and prevalence (high, low) (Accardo, 2007). Impairments with high severity and low prevalence include classical (Kanner's) autism (1–2 per 1000) and significant intellectual disabilities (IQ < 50–55) with a prevalence of 5 per 1000. Those with low severity and high prevalence include mild intellectual disabilities (30 per 1000), language disorders (100 per 1000), and learning disabilities (70–100 per 1000). It is because of these latter categories that as many as 20% of school-aged children may qualify for special education accommodations. Mild intellectual disabilities are defined as an IQ of 55 to 70, with adaptive skills more than 2 SDs below the mean, and are often detected in kindergarten and early elementary grades. These children are independent in communication skills and all activities of daily living. Reading and writing skills usually advance to a fifth-grade level before leveling off. Children with moderate intellectual disabilities ultimately have IQs of 40 to 55 and present with preschool language delay that later is diagnosed as a more complicated disability. These children are independent in all activities of daily living and eventually able to communicate basic needs to a caregiver. The major sequelae of this group of disorders are difficulty in complex academics, especially in reading paragraphs and writing book reports. A key question is: What are the differences in diagnosis and developmental outcomes among children with cognitive, language, and ASDs?
Rapin led a multisite multidisciplinary project whose purpose was to investigate the neurobiologic basis of ASD and related communication disorders, provide a basis for rational interventions, and improve the training of professionals who educate and care for these children (Rapin & Autism and Language Disorders Nosology Project, 1996). The cohort involved 487 children aged 3 to 7 years. Developmental language disorder (DLD) was present in 41%, ASDs were present in 36%, and intellectual disability without autism was present in 23%. The children were further divided into high-functioning autistic disorders (HADs; n = 51) and low-functioning autistic disorders (LADs; n = 125). The high-functioning group had nonverbal IQs greater than 80, whereas the low-functioning group had nonverbal IQs lower than 80. All children received a comprehensive assessment of neuropsychologic processes including language, nonverbal intelligence, adaptive behaviors, academic abilities, and neuromotor skills. Detailed histories of prenatal, perinatal, and postnatal events; childhood illnesses; family illnesses; developmental milestones; and growth, physical, and expanded neurologic examinations were noted.
Several findings were reported. The presence of developmental disabilities in parents and siblings was generally not a significant predictor for DLDs or ASDs. However, in families where one child had an ASD, there was an increased risk for other children to have either DLDs or intellectual disability. In a smaller number of families with one child with ASD, there was a second child with this disorder. Neonatal problems were generally not predictive of ASD or significantly different between the DLD and the ASD.
With respect to early developmental milestones, no child with a DLD or an ASD was a late walker, defined as not walking independently at age 18 months. Late walking was present in 25% of children with global developmental delay. Difficulty with pretend play at 36 months occurred in 25% of children with DLDs, 49% of children with global developmental delay, and 71% of children with ASDs. By age 4, only 5% of children with DLDs could not engage in pretend play whereas 1 in 6 (>15%) of high-functioning children with autistic disorders and 1 in 6 children with global developmental delays continued to struggle with these play skills.
Table 3 illustrates that delays in communicating in phrases and following 1-step commands significantly differentiated children with ASD from children with DLD. These findings also highlight why concerns about communicating in words and phrases and following requests without gestures are key first signs for the early recognition of autism. Overall, children with DLDs performed better in both receptive and expressive language skills than children with ASD and low nonverbal intelligence. These findings also suggest that enhancing communication skills is one of the key requirements for preschool interventions.
Rapin concluded that most prenatal, perinatal, and postnatal events did not differentiate between DLDs, high-functioning ASD, autism with intellectual disability, and mental retardation. Developmentally, 31% of the intellectual disability group and 56% of the autism group with nonverbal IQ less than 80 had significantly low IQ scores (IQ < 50). This study replicated findings from the multicenter Collaborative Perinatal Project that perinatal events do not play a strong causative role in autism, intellectual disability, and DLDs (Nelson, 1991).
Autism and ASDs have received a lion's share of public and media attention. There is also increased recognition that has contributed to higher clinical and administrative prevalence rates over the past 2 decades. Although families and research scientists may differ on the root-causal pathways for this increase in prevalence (Baird et al., 2000; Fombonne, 2003) of children either diagnosed or currently receiving specialized treatment for ASDs, it is timely that the primary healthcare professional assumes a leadership role in guiding and supporting families during the early diagnostic process.
Primary healthcare professionals, however, face several obstacles. First, they are increasingly called upon to screen for autism and other developmental disorders as part of the "well child" visits without adequate infrastructure for time and reimbursement considerations (Dosreis, Weiner, Johnson, & Newschaffer, 2006). Second, although national initiatives at the Center for Disease Control and Prevention (Autism Information Center) and policy statements (Committee on Children With Disabilities, 2001b; Filipek et al., 2000) have recommended specific autism screening tools and diagnostic standards (ICD 10, DSM IV), so far very few publications have addressed the effectiveness of the implementation of these strategies. Finally, because there is no laboratory or blood test for autism, the diagnosis remains open for subjective interpretation of even formal diagnostic standards. However, consensus exists that expert clinical judgment is more reliable than algorithm diagnosis in the youngest of children (Charman & Baird, 2002). These factors separately or in combination all serve to add obstacles and confuse the role pediatricians and primary care providers play in the diagnosis and management of ASDs (Committee on Children With Disabilities, 2001b).
Primary care providers can find guideposts in this changing landscape by beginning with the ICF strength-based framework and reviewing the principles of the early childhood diagnostic assessment. One goal of this review is to provide a bridge for the primary care provider as the information about the prevalence, diagnosis, and optimal management of ASDs evolves.
Four converging factors regarding the diagnosis of ASD highlights the importance of this review. Improved ability to diagnose ASDs at earlier ages (Lord, 1995; Moore & Goodson, 2003) is linked with pressure to meet early intervention or school-based special education eligibility requirements and fueled by emerging information about the effectiveness of early identification and treatment (Lovaas, 1987; McEachin, Smith, & Lovaas, 1993; Sheinkopf & Siegel, 1998). However, at the same time, there is emerging and conflicting information about the long-term stability and sensitivity of this early diagnostic process (Charman et al., 2005; Zwaigenbaum et al., 2006). It is not known which of these factors plays the dominant influence in the unmet needs experienced by children with ASD.
Our clinical experience has often reminded us that the primary healthcare provider is frequently the first to identify and respond to a family's developmental concern, and it is critical they understand and play a central role in overseeing the family's successful negotiation of the evaluation process. Equally important, the primary healthcare provider plays an integrative and educational role for the family after the diagnostic assessment is completed and when follow-up with the referral source is limited.
Based on the work of Meisels and the Zero to Three Work Group on Developmental Assessment, the principles of an optimal developmental assessment that best serve the family and primary care provider have been summarized in Table 4 (Greenspan & Meisels, 1996; Meisels & Atkins-Burnett, 2000; Meisels & Shonkoff, 1990; Shonkoff & Meisels, 2000).
The best practice components of a developmental assessment for young child with delays in communication, social skills, and developmental competencies should first contain multiple sources of information about the child's developmental progress and functional capacities. This requires that not only the parents but also the healthcare provider's and, possibly, the day care provider's concerns and description of the child's strengths and weaknesses be part of the diagnostic process. A primary healthcare provider should be alarmed on behalf of the family when the referral diagnostician does not solicit or accommodate the developmental history and primary care perspective of the child from the previous well child visits in the diagnostic assessment.
Second, primary healthcare providers shoulder the responsibility for increased mandates for developmental screening for ASD (Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, & Medical Home Initiatives for Children With Special Needs Project Advisory Committee, 2006). This responsibility and role increases the primary care provider's part in the developmental assessment process because collaborative and sequential assessments are central to any high-quality autism early identification, assessment, and family support management program.
Third, as primary care providers and systems of care become increasing adept in providing a medical home for children with ASD and other special healthcare needs, they need to join with the parents in identifying the child's current competencies and strengths as well as the skills the child needs to develop to continue with his or her developmental progression. Providing tips for "surviving your child's developmental assessment" (Seven Tips for Surviving Your Child's Developmental Assessment assessed at http://www.zerotothree.org/site/PageServer?pagename=ter_screen_tips) is one way the primary care provider can remain connected to parents as they embark on the developmental diagnostic process for their child and strive to manage the child's lifelong condition after the diagnostic assessment.
Finally, the ultimate goal of developmental and diagnostic assessments appropriate for the ICF strength-based model and the medical home is that no parents will suddenly face as part of the diagnostic process the reality of uncovering a problem that they did not suspected. When primary care fulfills its ideal role, parents are heard and supported up to, during, and after any referral multidisciplinary assessment. In addition, the primary care provider plays an important role for the parents who have difficulty in relating the initial behavioral or developmental concerns with the outcome of a diagnosis of ASD. Keeping the child and the child's behavior as the central focus of the parent's concern and the focus of the diagnostic process helps parents recognize their child's personhood in the diagnosis process. The primary care provider's facilitation of parental observations after the diagnostic process and understanding the terms of the diagnosis of ASD is an invaluable support as parents adjust their internal view of their child (Baird et al., 2000). Even when parents perceive the initial diagnosis of ASD as unwarranted and premature, primary care providers can adopt the "working diagnosis" perspective and join with the family to refine the diagnosis over time. It is in this context that the National Academy of Science recommendations are most pertinent. This committee recommended that all children with any ASD, regardless of label or level of severity, be eligible for special education services that comprehensively address social, cognitive, communicative, and learning skills. The therapeutic nature of this supported diagnostic process for parents should not be underestimated (Parker & Zuckerman, 1990) because it allows the introduction of structured services and for the priority of early intervention services to address communication and social skill challenges without driving parents to risky and unproven alternative treatment (Hyman & Levy, 2005).
Parents of children with autism are barraged with promises of miracle cures, drug therapies, and nontraditional therapies to cure their child (Nickel, 1996; Tanguay, 2000). Many times, caregivers are willing to try anything to help their child. Nonethical promoters of nonscientific therapies use common ploys to seduce desperate parents into trying their treatments. Some common approaches include exploiting the natural fear of disease, preying on the uncertainty about traditional medical care, promising painless and natural treatments, and claiming miraculous scientific breakthrough and developmental cures.
One promise of a scientific breakthrough was the use of secretin to cure autism. A case study was reported in the literature that 1 dose of intravenous secretin costing more than $1000 successfully eliminated symptoms in a child with autism (Horvath et al., 1998). Several scientific studies have been conducted since the original case study. One undertaken by Coniglio et al. (2001) involved children aged 3 to 10 years diagnosed using DSM-IV criteria for autism. The goal was to determine whether a single dose of intravenously administered secretin could improve communication and socialization skills in children with autism. Subjects were randomly divided into treatment and placebo groups. The Childhood Autism Rating Scale and Preschool Language Scale–3 (PLS-3) were administered at baseline, 3 weeks, and 6 weeks after treatment. In addition, caretakers completed the Parent Perception Survey and the Gilliam Autistic Rating Scale and were asked several study-specific questions including "Do you believe your child received secretin? Have you noticed any changes in your child's symptoms?" Results showed that children who did not receive secretin made more communicative, behavioral, and developmental progress using these standardized outcome measures.
In another study, Sandler et al. (1999) randomly assigned 60 children aged 3 to 14 years to either a single treatment secretin group or a placebo control group. DSM-IV criteria were used to diagnose autism (Sandler et al., 1999). If autism criteria were not met, PDD was diagnosed. Subjects were administered the Childhood Autism Rating Scale and the Autism Behavior Checklist at baseline and at a 4-week follow-up. Again, the children assigned to the placebo treatment improved on these behavioral measures more than the secretin group. To date, there have been several other secretin trials involving more than 700 children with autism (Dunn-Geier et al., 2000; Lightdale et al., 2001; Owley & Steele, 1999; Roberts et al., 2001). In no trial was secretin a miracle cure. However, in all trials, improvement occurred over time in all children with ASDs, thus demonstrating that all children with ASDs learn. Despite the lack of evidence for secretin's therapeutic use and even after being presented the study's negative results, parents continued to ask the study doctors for ongoing secretin treatment.
Primary care professionals need to embrace the passion parents demonstrate in their search for supports to their afflicted child. Rather than a punitive remark or avoiding a discussion about an alternative treatment, primary healthcare professionals can play a positive role by providing families valuable information to evaluate any alternative treatment. We have found some useful Web sites and handouts to offer to families when contemplating the complex issue of and risks associated with alternative treatments.
1. http://www.asatonline.org/ (Association for Science in Autism Treatment, n.d.)
2. http://www.autismresearchnetwork.org/AN/default.aspx (National Institutes of Health Autism Research Network, 2007)
3. Parent handouts have been developed by The Autism Program. These include:
a. Current Interventions in Autism— A Brief Analysis at http://www.theautismprogram.org/autismtreatments.asp (The Autism Program, n.d.-a)
b. Tips for Working With Children With Autism Spectrum Disorders at http://www.theautismprogram.org/tips.asp (The Autism Program, n.d.-d)
c. Top 10 Things to Remember When Working With Children With Autism Spectrum Disorders at http://www.theautismprogram.org/top10.asp (The Autism Program, n.d.-e)
d. Tips for Daily Life—Visiting the Dentist at http://www.theautismprogram.org/dentist.asp (The Autism Program, n.d.-b)
e. Tips for Daily Life—Toilet Training at http://www.theautismprogram.org/toilet.asp (The Autism Program, n.d.-c)
The primary healthcare provider, as the central figure in the medical home and because of his or her unique training, interest, and commitment, is perfectly positioned to understand and support the special family circumstances that each family brings with a child who has developmental differences. Unfortunately, Medicaid and private party payers do not value this expertise or commitment with their reimbursement schemes. Primary healthcare providers, pediatricians, and nurse practitioners and family practice specifically are best positioned to involve family members in planning the evaluation of a child's development. They also foster respectful communication between parents, referrals to subspecialty physicians, and allied healthcare and educational professionals. Helping families integrate the different pieces of an assessment for ASDs (genetics, hearing, neurologic, and educational) is one valuable mandate of the medical home.
The American Academy of Pediatrics, and its national medical home initiative (American Academy of Pediatrics: The National Center of Medical Home Initiatives for Children With Special Needs, n.d.), has advocated a model of primary care delivery that keeps the primary healthcare professional central to the process of identification, family understanding, professional referrals, and diagnostic assessment for children with developmental differences. At the same time, this initiatives at the American Academy of Pediatrics endeavors to find political and legal avenues to address the negative financial setbacks that most primary care providers risk when they choose to maintain this central role for their patients and families. The American Academy of Pediatrics has a toolkit as well as updated brochures to enhance the primary care provider's skills (see www.aap.org). In addition, the National Medical Home Autism Initiative at the University of Wisconsin and the Maternal and Child Health Bureau (MCHB) is evidence, in part, of the way national organizations and federal agencies are promoting and providing technical assistance to pediatric healthcare providers who desire to work with other partners in the community to serve children with autism (Fig. 1).
Adopting the ICF model with a strengths- and supports-based framework for describing preschool children with ASD is a perfect match for primary healthcare professionals. In collaboration with the larger community of providers, the key goal is to provide comprehensive coordinated and compassionate care for children and families faced with the challenges of ASDs.
Building on the ICF framework of enablement, primary care providers will have the structure to communicate with sensitivity and mutual respect information about the developmental diagnosis, explain current medical understanding of autism to families, and provide ongoing family support. Only then will families have the confidence to increase their requests to primary care providers for guidance about the range of traditional and nontraditional autistic-specific treatments available. In addition, this framework allows the physician to prioritize interventions that promote child functioning and enhance family well-being.
The blending of the ICF framework within the primary care structure of the medical home can serve to reveal the added value of decreasing fears and stresses through efficient parent-professional partnerships. This added value reflects the teamwork of professional and nonprofessional office staff toward family-centered care management and enhanced communication. These models also recognize the wide range of differences in challenges families of children with autism face and the increased time and effort required for the ongoing monitoring of the child's progress and family adaptation.
The major need for families is to feel that their primary healthcare professional listens to their concerns and understands the multithreaded information required for a diagnostic assessment. Parents also need to be continually supported in accessing comprehensive systems of early intervention and preschool education on behalf of their child. It is most important to view ASD as a developmental disorder whereby interventions to enhance communication, promote adaptive skills, and build on the child's strengths occur. It is a dangerous practice to assume that there is a magic bullet that will dramatically cause the child to be suddenly typical. Unfortunately, the complexity of human language and the developmental neurobiology of autism do no allow for cures with injections of miracle drugs or nutrition supplements (Coury & Nash, 2003; Ozonoff et al., 2003; Volkmar & Pauls, 2003). Instead, ASD allows us to understand how all children can benefit from comprehensive and quality supports that enhance communication, adaptive skills, and functional independence at home and in the community. If the parent or the child experience challenges that are too demanding or out of control, they will not understand the current behavior and educational technologies that can make a difference (Rogers, 1998; Siegel, 1996, 2003; Smith, Eikeseth, Klevstrand, & Lovaas, 1997; Wetherby & Prizant, 2000; Wing, 2001). The role of the physician is not to be an expert on all educational practices but to know the hard task of parenting children who are motorically able but communicatively challenged and behaviorally unpredictable. Attention to family stresses and daily management supports can make a difference at home, school, and in the community. In this way families can undertake the multidimensional management strategies that promote functional, communicative, social, and adaptive skills. They then can celebrate with professionals the strengths of their child's unique way of experiencing the world and set goals that promote steps to independence, and when challenges persist, know they will not be abandoned.
autistic spectrum disorders; counseling; family supports; functioning
©2008Lippincott Williams & Wilkins, Inc.
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May 2007
Action: Reaction
On this superb outing, seven-string jazz guitarist Steve Herberman exhibits a vast harmonic palette involving uncommon stretches on the fretboard along with a real capacity to burn on fluent single note lines. Alternating between a deft fingerstyle approach on rich chordal melodies, a technique that allows for more contrapuntal voicings, and using a pick on accelerated single note runs, Herberman gets the best of both worlds on his instrument. Hearing his sheer command of the instrument on pieces like the burning bop-fueled "Cos' Groove," the darkly introspective "Negev Journey" and jaunty swingers like "Be Nimble" and "Sphericity" immediately puts one in mind of such jazz guitar masters as Joe Pass, Joe Diorio, Lenny Breau and Gene Bertoncini. His nuanced touch, excellent tone, tasteful, even phrasing and fresh writing style, particularly on delicate ballads like "Halcyon Air" and "Nearly Time," the challenging intervallic vehicle "Snap!" or the angular boogaloo "Worry Not," further elevates Herberman far above the pack of other talented Berklee grads now looking to find their place in the jazz world.
The D.C.-based Herberman also excised good judgment in recruiting New Yorkers Drew Gress and Mark Ferber for his rhythm section on his project. Gress, a stalwart on New York's downtown scene, is one reliable groovemeister and one of the most creative improvisers around. His tone is huge and his time feel on swingers like the up-tempo "Cos' Groove" and mid-tempo numbers like "Shoutin' Down" and "Sphericity" is solid and unerring. And his melodic solos on the bossa-flavored "Halcyon Air" and on "Nearly Time" contain rare beauty. Though highly regarded inside the alternative jazz circles, the largely underrated Ferber shows uncommon empathy throughout this session, along a relaxed, rhythmically assured sense of swing, as he aptly demonstrates on "Shoutin' Down," which features some hip exchanges between guitarist and drummer.
Herberman's follow-up to 2001's Thought Lines is definitely worth checking out for fans of advanced jazz guitar.


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It's Wednesday morning in Chicago, day 5 of our road trip and round the world journey. While we knew there was a lot to do on this trip, it's surprisingly tiring. There is a lot of driving, planning, and changing plans. So far, though, we're on schedule.
We've met up with bitcoiners in Denver, Kansas City, and now Chicago. We're excited to meet up with more in Pittsburgh, New York, and then off to Stockholm, Berlin, and Singapore.
We've been so caught up in the trip that I haven't posted something I promised I would; the pamphlet we put together for merchants considering bitcoin.
The trifold pamphlet is very simple. With the text of the pamphlet, we didn't go in to deep detail about bitcoin. We've found that becoming highly technical will lose many more merchants than it will help. This is just a first contact, very basic intro. This is something you can leave in their hand, with your contact info written on the back.
Here is a sequence that may help you bring a business around to accepting bitcoin. Use and modify as you see fit.
1. Find merchants that you think are in a good position to begin accepting bitcoin (see our blog post about which merchants are likely candidates). Be brief, and leave this pamphlet.
2. Return within a few days (no longer than a week) and discuss the possibility of bringing a "bitmob", or a larger group of people all paying in bitcoin. If they're open to the idea, send them setup instructions for a payment processor, like Bitpay or Coinbase. Approval for these merchant accounts can take a few days, so make sure they understand and apply for an account at least a week before your prospective bitmob. If they're still concerned, you may want to consider putting cash down on the spot (maybe $100) to put their fears to rest. Call it a down payment on the upcoming group dinner, and they can take it out of the bill when you call come for the bitmob.
3. Find out when they've been approved for the merchant account. There are still a couple things they need to do to finalize the account, like connecting it to a regular bank account. Run a trial purchase to make sure everything is up and running. You'll be their first bitcoin customer!
4. On a pre-designated night, when you, the merchant, and local bitcoiners have all agreed, show up with your local bitcoin meetup and have a great time! This is a fantastic activity to help spread bitcoin and enjoy yourselves all at once.
If you feel like your merchant will need more time through all this, introduce them to paper wallets or real coin bitcoins, like casascius coins. "They're like gift cards", you can say. Leaving something in their hands, even a paper wallet worth 5 satoshi, will help them become more comfortable with bitcoin.
As I finish writing this, it's Wednesday afternoon, on the road from Chicago to Pittsburgh. We're only a few days into our round the world trip, but it's already feeling like a whilrwind. It's coming together, thanks to the support along the way from the bitcoiners we encounter. Thanks everyone. Wish us (continued) luck.


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Heat waves can cause playground skin scalders
By Samantha Kramer, AccuWeather.com staff writer
Jun 27, 2012
With this week reaching extreme temperatures in the mid-90s across the Northeast, parents worry about the usual cautions for their kids: making sure they get enough water, putting on plenty of sunscreen, or wearing cool, light clothing.
But one thing many parents don't realize as a danger is one of their children's favorite places: playgrounds.
Even in 80-degree temperatures, if a plastic or metal slide is sitting in the sun, it can reach up to 160 degrees F.
And though it may seem obvious on hot summer days, it's something that most parents don't even think about, said Geoffrey Croft, president of NYC Park Advocates.
"A lot of [New York's] parks have warning signs, but 99 percent of people don't read them," Croft said. "A two-year-old doesn't adhere to a warning sign."
AccuWeather.com investigated a nearby playground in State College, Pa., and found that a light-colored, plastic slide had reached 142 degrees, while a black plastic swing heated up to 156 degrees -- two degrees short of being able to fry an egg.
Read the full article here.


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Producer Responds After Cringe-Worthy Version Of Britney Spears' 'Alien' Without Auto-Tune Leaks
If you've heard Britney Spears' single Alien, you can hear a bit of auto-tune leveling out Britney's singing. However, a recent leaked version of the song featuring no production at all is making music fans wonder if Britney can sing at all.
The leaked version, above, features Britney singing to the song's instrumentation without any production done to her voice. It's... bad. Now, the track's producer William Orbit has released a statement claiming the leaked version is a vocal warm-up and not the take that was produced for the album.
He wrote on his Facebook page, "Dearest Music Lovers, I have heard that Britney vocal link that everybody's been discussing. It has been impossible not to as there have been many comments directing my attention to it. I'd like to affirm that ANY singer when first at the mic at the start of a long session can make a multitude of vocalisations in order to get warmed up.
"Warming up is essential if you're a pro, as it is with a runner doing stretches, and it takes a while to do properly. I've heard all manner of sounds emitted during warmups. The point is that it is not supposed to be shared with millions of listeners.
"A generous singer will put something down the mic to help the engineer get their systems warmed up and at the right level, maybe whilst having a cup of herb tea and checking through lyrics before the session really kicks off. It's not expected to be a 'take.'"
It's not the first time Spears has been accused of enhancing her voice. Several years ago a video (above) surfaced claiming to reveal Spears' isolated vocals during a concert. Many were quick to point out that backing tracks are common for concerts feature a lot of dancing or similar set pieces – and Spears had those in spades.
We'd think if this was a real leak of Spears' singing track used in the song, the producer would just keep quiet and hope it all goes away. Orbit's explanation holds water, but do you believe him? Do you think this is Spears' singing voice or was they just warming up for the real deal?


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Welcome to the Utah Public Notice Website: Your central source for all public notice information in Utah
Department of Commerce:
Physician Assistant Licensing Board
Entity: Department of Commerce
Body: Physician Assistant Licensing Board
Subject: Occupational Licensing
Notice Title: Physician Assistant Licensing Board meeting
Notice Type: Meeting
Event Start Date & Time: January 27, 2014 8:30 AM
2nd Agenda UTAH PHYSICIAN ASSISTANT LICENSING BOARD January 27, 2014 Room 474 – 4th Floor – 8:30 am Heber M. Wells Building 160 E. 300 S. Salt Lake City, Utah This agenda is subject to change up to 24 hours prior to the meeting. ADMINISTRATIVE BUSINESS: 1. Call Meeting to Order 2. Sign Per Diem 3. Read and Approve the December 16, 2013 Minutes APPOINTMENTS: 8:30 am – Compliance Unit Update 9:00 am – Mr. Hansel Rayner, Probationary Interview and Dr. Paul Satter, Supervising Physician DISCUSSION ITEMS: • Discontinue the CS Law/Rule Exam CORRESPONDENCE: NEXT SCHEDULED MEETING: March 17, 2014
Notice of Special Accommodations:
In compliance with the Americans with Disabilities Act, individuals needing special accommodations (including auxiliary communicative aids and services) during this meeting should notify the Division ADA Coordinator at least three working days prior to the meeting. Division of Occupational & Professional Licensing, 160 East 300 South, Salt Lake City, Utah 84115, (801) 530-6628 or toll-free in Utah only (866) 275-3675.
Notice of Electronic or telephone participation:
Electronic participation is not planned for this meeting.
Other Information
This notice was posted on: January 08, 2014 02:19 PM
This notice was last edited on: January 13, 2014 04:24 PM
Board/Committee Contacts


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Where is the Petronas Twin Towers? Map and directions to the location with picture. Di mana Petronas Twin Towers? Peta dan panduan ke lokasi dengan gambar…
Address: Kuala Lumpur City Centre, 50088 Kuala Lumpur, Malaysia
Alamat Poskod: 50088 Kuala Lumpur
Tel: +603 2051 5000 Fax: +603 2026 5050
Website: http://www.petronas.com.my/
GPS Coordinates: N3 09.469 E101 42.701
Info: The corporate headquarters of Petroliam Nasional Berhad is located in the iconic Petronas Twin Towers at KLCC. Completed in 1996, it was once the world's tallest building at 452 meteres. Kuala Lumpur City Centre consists of the Petronas Twin Towers, Suria KLCC Shopping Mall, Dewan Filharmonik Petronas (Philharmonic Hall), Menara Maxis, Kuala Lumpur Convention Centre (also abbreviated as KLCC), Aquaria KLCC, Masjid As-Syakirin (KLCC Mosque) and KLCC Park.
A sky bridge at Levels 41 and 42 connects the two towers. The double-deck skybridge is opened to tourists from 8:30 am to 7.00 pm on Tuesdays to Sundays.
See other featured Places of Attraction or use Search to locate another attraction.
MyCen Map / Peta:
Landmarks: Petronas Twin Towers (X), Suria KLCC (1), Menara Maxis (2), Mandarin Oriental Hotel (3), KLCC Park (4), Grand Hyatt Hotel (being-built) (5), KL Convention Centre & Aquaria KLCC (6), Traders Hotel (7), Menara ExxonMobil (8), Masjid As-Syakirin (9)
Nearby Hotels: Mandarin Oriental, Traders Hotel, Impiana KLCC, Corus Hotel, Novotel
Nearest Police Station: Balai Polis Dang Wangi
Nearest Train Station: KLCC LRT Station, Ampang Park LRT Station
Public Transport / Bus Number:
Need to find another place, street, building or area? Use Search
Ingin cari tempat, jalan, bangunan atau kawasan lain? Guna Search


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Royal Sun Resort
No prices found through our partners. Please contact the business directly or check some of our recommended alternatives.
- Shuttle bus service
- Microwave in room
- Reduced mobility rooms
- Kids pool
- Room service
- Russian TV Channels Available
Photos of Royal Sun Resort
- Kids pool
- Heated pool
- Swimming pool
- Restaurant
- Outdoor pool
- Fitness/Health center
- Bar/lounge
- Microwave in room
- Reduced mobility rooms
- High-speed internet in room
- Breakfast Available
- Wireless internet connection in room (free)
- Wireless internet connection in public areas
- Refrigerator in room
- Wheelchair accessibility
- Kitchenette
- Family rooms
- Shuttle bus service
- Room service
- Russian TV Channels Available
- TV RTR Planeta Russia
- TV Channel One Russia
- Multilingual staff
- Laundry
- Meal plan
- Kids activities or Babysitting
TripAdvisor Reviews Royal Sun Resort Puerto de Santiago
Travel Blogs from Puerto de Santiago
A trail run for renewed real travelling
... at once and I felt totally relaxed and possibly just begining to wonder what was over the next hill.
We are now back at our recently acquired home in Eastbourne, close to our latest grandson and family. The Canaries trip proved a good test for further trips but I'm told the need for realism in planning a more appealing and adventurist journey is needed; such realism restricts my instincts.As you all know dreams can come true and occasionally do.
A little piece of paradise.
... I hope I get to go back someday.
So as to what I did, I am probably not going to say much on this because a picture is worth a thousand words. But I will tell you about he boat trip I took on a Catamaran to whale and dolphin watch was so beautiful it was practically spiritual. Apparently, this type of boat is very popular with the dolphins so they come right up to the boat to play in the wake made by the pontoons. I swear, they ...
Tourist-ing Out in Tenerife
... out beside our bed...I could actually see his individual eyeballs. It was gross. I thought about putting a glass over him and leaving him for the maid to deal with but decided to try and remedy the situation myself while Mike helpfully asked if I'd like him to help me from somewhere in the vicinity of the hallway. I declined and whacked Señor Cucamunga with a flip flop. In retrospect a boot would have been a better idea because I then had to step on the flip flop to finish ...
Returning home
... skill?? Plus we debated yet again, who would be Pinky and who should be the Brain!
Burger King at the airport - yes to a Whopper! Then aboard our flight. Had great sunset views with the volcano: El Teide sillhouetted against the back drop and the clouds falling away beneath us. A perfect end to a perfect trip. Our first together, but hopefully not our last.
Claire & ...
Yet more time to relax
... unable to work out what time it was. I tried to be optimistic that this wasn't a sign of San Fran's continual edging towards a chasm of uselessness but I had to admit he was getting less and less reliable. A saunter back to our apartment allowed us to take in the night life one last time as unfortunately we return home tomorrow.
Claire & ...
Other places to stay in Puerto de Santiago
Globales Aparthotel Tamaimo TropicalCalle La Hondura S/N, Puerto de Santiago | 3 star hotelfrom $35
- Best Holiday yet
Luabay Costa Los GigantesJuan Manuel Capdevielle 8, Puerto de Santiago | 4 star hotelfrom $165
Blue Sea Hotel Lagos De CesarC/Jose Gonzalez Gonzalez, Puerto de Santiago | 5 star hotelfrom $54
Bahia FlamingoAvenida de la Gaviota, 3, Puerto de Santiago | 3 star hotelfrom $56
- Who gave it a 3* Rating?
- Basic and friendly hotel - poor food
- Fun at the bahia flamingo
El Marques PalaceCalle Rosas s/n, Puerto de Santiago | 3 star hotelfrom $85


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THQ boss Danny Bilson has noted that Relic will announce a new Real-Time Strategy title in August this year.
Relic are well known for the high quality of their Real-Time Strategy games, with a repertoire including the brilliant Company of Heroes and the much-loved Dawn of War series. What do you guys think it will be? New CoH? More Dawn of War? Something completely new? Let us know in the comments what you think.
Via RPS


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ALSO, D2B, Itancia: new brands for French distributors
France: broadliner ALSO has expanded its Value portfolio with the full portfolio of GFI Software security, network and email solutions. Meanwhile, security and storage VAD D2B has unveiled in just a few days two additions to its portfolio, G-Data and Barracuda Networks. Through these deals, G-Data wishes to target more efficiently the system integrator and VAR networks in the country, while D2B, while able to distribute the full Barracuda Networks offer, will focus mainly on its cloud and data protection solutions. Finally, already a Yealink VoIP distributor, telecom VAD Itancia has expanded its partnership with the vendor to its video-conferencing offer.
Westcon UC&C in video with Polycom
France: a few weeks after its competitor Itancia, network and telecom VAD Westcon UC&C has expanded its partnership with Polycom to include its video-conferencing products.
Itancia in video with Polycom
France: previously a Polycom audio-conferencing distributor, network and telecom VAD Itancia has extended its relationship with the vendor to its video-conferencing offer. This partnership follows an excellent growth of Polycom sales by Itancia over the two past years, which are rewarded with this new deal.
A new marketing director for Audim
France: following the departure of Alexandre Marie to ecorecycling and telecom VAD Itancia, Didier Tuil, the development director of mobility specialist Audim, becomes the new marketing director of the distributor.
Some new heads for Itancia
France: after its marketing director Emmanuel Dubois who joined VAD Integrasys-HL2D, Cynthia Sayegh has left telecom VAD Itancia to join the sales team of VoIP vendor Audiocodes. She is replaced for communication by Alexandre Marie, the former marketing director of telephony specialist Audim, who joined the VAD as marketing director. He works with 4 dedicated product marketing managers (eco-recycled products, Smart Technologies, VoIP and Unified Communications).
Itancia France
Itancia France
Président :
M. Yann Pineau
Année de création : 1991
Câblage et connectique
électronique grand public
Protection électrique
Téléphonie (analogique, RNIS, mobile)
Vidéo professionnelle
Services à valeur ajoutée


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Local educators question charter school proposal
Rutland Selectman Louis J. Cornacchioli was one of a number of people who spoke out about a charter school that would be open next year to students from the Wachusett Regional School District.
Cornacchioli spoke at a December 11 public hearing at Levi Heywood Memorial Library in Gardner. The former Wachusett Regional High School teacher and current representative for the Massachusetts Teacher Association in Worcester said he didn't know if the proposed charter school's mission is to enroll students who are considered gifted and therefore bored in a regular classroom, or students with behavioral or educational issues who struggle in a regular classroom.
Maplewind Community Charter School is one of four charter schools that could be approved by the Department of Education to open in the 2007-08 school year.
"Maplewind will establish the arts as part of the core curriculum," according to the school's proposal. "It will approach this by interdisciplinary curriculum, team teaching and a schedule that allows for equal time and weight for all courses."
The school would operate on an eighthour and 15-minute school day, serving 240 students in grades 7-12.
Maplewind would draw students from 17 towns, including Ashburnham, Westminster, Holden, Paxton, Rutland, Princeton, Sterling, Oakham, Gardner, Hubbardston, Winchendon, Templeton, Phillipston, Petersham, Barre, New Braintree and Hardwick.
Russell Killough-Miller, who is organizing the charter proposal, said there is a need for a charter school option in the region.
"We're offering this as an alternative for students not getting what they need for curricular reasons, or for pedagogical reasons," he said.
Killough-Miller said there would be a minimal impact on the local districts because the charter school, if approved, would be open to students from a large number of communities.
Cornacchioli asked how the school was going to pay teachers a competitive rate, and still be able to afford to stay open.
"I don't see that happening," he said.
Ashburnham-Westminster Regional School District Superintendent Michael Zapantis, Winchendon Superintendent of Schools Peter Azar, Narragansett Regional Superintendent Stephen Hemman and Narragansett's school committee chair also spoke against the project. They questioned the charter school's ability to take special education students, and are concerned about the state formula for funding charter schools.
"Will the staff be one that is able to take some of our most challenging students?" asked Azar.
District to respond
Wachusett Regional School District Superintendent Thomas Pandiscio didn't attend the hearing, but plans to meet with the school committee to craft a response to the Department of Education by the January 2 deadline.
"When you look at charter schools, you have to ask, what need are they filling?" he said. "Is it a need already being met in the surrounding districts? Is it causing a hardship in districts?"
He said Princeton would be most affected because it is already struggling with declining enrollment.
"[Charter school founders] argue that the school would offer a strong arts program," he said, "while we think they're duplicating needs that are already being met, and which will produce a strain on taxpayers."
The state has a formula that offsets the loss of per-pupil state aid to districts, he said, but that doesn't help when a Wachusett classroom that was once full is now minus several students — and, in effect, their state money — that went toward paying the district teacher's salary. "Public school educators as a whole
are pretty much against charter schools," Pandiscio said. "They're against anything that duplicates services while diminishing your state aid and increasing your costs.
"By losing students to charter schools, you haven't reduced your budget, but the ability to pay your school costs with state aid money. It's a revenue thing," he said.
Parents speak in favor
Three parents from Hubbardston spoke in favor of the proposed school at the December 11 hearing.
"The idea of an integrated arts program is unique," said Renee Malowitz, a member of the school's founding board.
Parent Donna Farrell said Maplewind Community Charter School is a positive thing because it offers an alternative form of education "without putting the financial burden on the families."
The state Department of Education will decide in February if Maplewind will be granted a charter.
Another public hearing will be held on Tuesday, December 19, at the State House in Boston from 4 to 6 p.m. and written comments can be submitted until Tuesday, January 2. Comments can be mailed to the Department of Education, Charter School Office, 350 Main St., Malden, MA 02148 or e-mailed to charterschools@ doe.mass.edu.


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Ladies Knight02/27/2014
Sir Knightly is in love with the Princess but his love is not reciprocated. When a fire-breathing dragon arrives, the Princess thinks he is way hotter than Sir Knightly, so she rides off with the dragon to his castle. Against the advice of the Singing Sword, Sir Knightly sets off to rescue the Princess with the help of his trusty steed, Doofus.
Ladies Knight was an official selection of NFFTY 2013 and won the Audience Award in the category of Happy Hour Shorts.
About the Director:
Joe Rothenberg is an independent animator, game developer, and cartoonist living in Burbank, California with 4 roommates, 2 dogs, and 4 cats. Upon graduating from USC in 2012, he started a game studio called Cup of Joe Games, opened an online store selling artwork under the name Joe Cartoon, and pitched a show called Joey to Nickelodeon. (He devotes his creative energy to his projects, so there's very little left over for naming things.)
NFFTY speaks to Joe about his inspiration behind this amusing, light-hearted short.
Q: How did you come up with the idea of doing a musical narrative instead of just presenting the story as a animated narrative piece?
Originally, I was planning to make a combination Looney Tunes/Hitchcock-style comedy thriller. I found myself struggling with the story, and eventually realized it wasn't fun enough. I decided to switch gears to something completely lighthearted and fun. A musical was just the thing. Plus, as a young filmmaker, I was pretty inexperienced writing stories, so I used the songs to help anchor the story and keep things moving forward.
Q: Could you walk us through your thought process of creating this film?
I felt like fairy tales always got romance wrong, so I wanted to portray young love more like the way I had experienced it. The story is loosely based on my dating misadventures in college and the feeling I sometimes got that I was a comedy relief character accidentally cast in a leading role. Genre-wise, I tried to embrace the musical while affectionately parodying it. The tap-dance scene, in particular, is an homage to unnecessary dance numbers that are practically ubituitous in classic musicals.
Q: Has participation in NFFTY helped to pave a way for your entry into this industry?
I'm proud to display the NFFTY laurels on my film's homepage. The recognition my film has received has opened the door to pitch opportunities at Frederator and Nickelodeon. We'll see what happens next. Thanks, NFFTY!
Wanting to write your own musical but have no idea where to begin? Joe's blog post on "What to remember when writing your first musical" will be up soon. Check back for more updates.


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International Edition
December, 10, 2016
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Foreign Ministry defends its actions in exhibit naming row
June 24, 2014, 12:09 am TWN
TAIPEI -- The Ministry of Foreign Affairs said yesterday that it has been working hard alongside Taiwan's representative office in Japan to deal with the controversy over the naming used to refer to the National Palace Museum (NPM) exhibition set to open Tuesday in Tokyo.
"We have made every effort to assist the NPM in asking the Tokyo museum to correct its name," said ministry spokeswoman Anna Kao in response to reports that Taiwan's representative office did not play a part in negotiations to handle the situation.
She said her ministry and the representative office also used diplomatic channels to lodge a protest over the naming row.
On Friday, the Foreign Ministry warned Tokyo National Museum, which is putting on the exhibition in Tokyo, that Taiwan will cancel the event unless advertisements and tickets that refer to the NPM as simply the "Palace Museum" are replaced with versions featuring its full name.
On Monday morning, the NPM announced that the exhibition in Tokyo will open Tuesday as scheduled after the Tokyo National Museum met demands to remove or replace all posters and advertising materials that were missing the word "national."
NPM Director Fung Ming-chu said she will attend an opening reception in Tokyo later in the day.
Amid the naming row, first lady Chow Mei-ching canceled her previous plans to attend the opening ceremony of the exhibition.
Selected items from the NPM are set to be put on display under the title "Treasured Masterpieces from the National Palace Museum, Taipei" at the Tokyo National Museum from June 24 to Sept. 15, and at the Kyushu National Museum from Oct. 7 to Nov. 30.
Controversy erupted because the removal of the word "national" constitutes an apparent violation of the agreement between Taiwan and Japan that the museum's full name must be used in all publicity materials.
The posters in question, which had been spotted at train stations and parks in Tokyo, were prepared by a media sponsor group comprising major media outlets including NHK, the Asahi Shimbun and other TV stations and newspapers.
But the posters also carried the images of NPM items, which meant that the Tokyo museum must have granted its approval for the media sponsor group to use, according to the Foreign Ministry.
The official posters and brochures prepared by the Tokyo National Museum itself refer to the Taipei museum by its proper name of "National Palace Museum."
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7 holidays to be eliminated next year
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Trump-Tsai call risks Beijing's ire


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GREENACRE, PHYLLIS (1894–1989), U.S. psychiatrist. Greenacre, who was born in Chicago, received a B.S. from the University of Chicago in 1913, and graduated from Rush Medical College in 1916. She was appointed clinical professor of psychiatry at Cornell University Medical College in 1935. In 1942 she joined the faculty of the New York Psychoanalytic Institute and was its president from 1948 to 1950. She served as president of the New York Psychoanalytic Society from 1956 to 1957. She was also vice president, and later honorary vice president, of the International Psychoanalytical Association. She served on the editorial board of the influential annual The Psychoanalytic Study of the Child, from its inception in 1945.
One of her main interests was the subject of anxiety. In 1941 she published a paper in which she sought the roots of anxiety in the birth trauma of the fetus, as revealed in the newborn child and in the memory traces of the adult patient in psychoanalysis. Birth, with its enormous sensory stimulation after the relaxed fetal state, in her view, produced a strong narcissistic drive and a defensive organization of anxiety in the infant. Her book Trauma, Growth and Personality was published in 1952.
A further focus of Greenacre's interest was the sexual anomaly of fetishism. She stressed the magical value represented by the fetish in early life as a result of disturbed mother-child relationships. She wrote, too, on identity and its relation to body image, stressing the role of visual perception and perceptual distortion in the fetish image of the genitals and face. In 1953 she edited Affective Disorders. Her analysis of the creative personality and imagination was set out in her study of two lives, Swift and Carroll (1955). Her other publications include The Quest for the Father: A Study of the Darwin-Butler Controversy as a Contribution to the Understanding of the Creative Individual (1963); and Emotional Growth: Psychoanalytic Studies of the Gifted and a Great Variety of Other Individuals (1971).
Sources:A. Grinstein, Index of Psychoanalytic Writings, 2 (1957), 6 (1964).
[Louis Miller /Ruth Beloff (2nd ed.)]
Judaica. © 2008 The Gale Group.
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The way forward is to boost economic growth and turn Africa's youth into entrepreneurs, which means looking at what is taught at schools and universities, among other elements.
• State targets youth unemployment
South African universities have teamed up with their Dutch counterparts to develop a course aimed at improving PhD supervision. Better and more doctoral supervisors, it is believed, will increase the number of PhD students.
• Cross-continental collaboration
The small village famous as the birth place of Nelson Mandela will soon have a school of science and technology. It is envisaged that the school will help improve South Africa's education standing, and open the doors to more career options for poor rural youth.
• Maths, science teaching gets boost
The Indiafrica Festival 2013, which takes place in Johannesburg between 13 and 24 May, marks the culmination of the second edition of Indiafrica: A shared future, an initiative that targets young entrepreneurs and artists from both countries.
• India and SA growing together
Technology is coming to the assistance of under-resourced rural schools in the form of Obami. On a road trip through the country, its creators "experienced hope. There's an undeniable sense ... that as a nation, we can pull together and conquer".
• Safe social portal for scholars
The government has started to work with the private sector and various organisations on a Youth Unemployment Accord, drawn up to get young people working.
• Helping street kids responsibly
A passionate volunteer, an NGO, and a few private sector groups wanting to get involved have made a real difference in the lives of children in Umlazi, setting up a music school and a library in converted containers.
• Getting internet from the sun


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Living cells rely on tiny electrical signals to work. Scientists believe that by redesigning cell structures they can use living material to process data in the way that a computer chip does. That is one form of biochip. The other is the tiny conventional microchip that can be linked to organic material to control its growth and operation. Another name for this science is molecular electronics.
Related category COMPUTERS
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MC honors employees
As Marietta College prepares to bid farewell to another class of graduating seniors, President Joseph W. Bruno is pleased to honor employees who have reached a milestone in service, as well as the six individuals who are retiring.
Starting at 10:30 a.m., Tuesday, May 7, the College conducted its annual Employee Award Ceremony in the Hermann Fine Arts Center foyer. The college begins recognizing service at five years and continues to do so in five-year increments.
Those recognized for their service to the college have combined for 620 years.
Four employees – Bob Chase (Petroleum Engineering), Rodney Delancey (Physical Plant), Linda Meade (Physical Plant) and Mary Zimmer (Library) – are celebrating 35 years of employment at Marietta College.
There are also six employees – Elaine Addis (Education), Barb Binegar (Library), Susan Dyer (Library), Connie Golden (Education), Sammie Meade (Physical Plant) and Steve Spilatro (Biology) – who have reached 25 years.
"As I get closer to completing my first year at Marietta College, I am honored that we have such a dedicated and loyal group of employees," Bruno said. "It is important that we recognize our employees in this fashion every year because they are a vital part of what makes Marietta College such an exciting and thriving campus. This is our day to say thank you to all of them."
Also honored on May 7 are:
20-year awards: Mark Bagshaw (Business & Economics), Jan Vaughan (President's Office), Ena Vulor (Modern Languages) and Sharon Warden (Admission).
15-year awards: Debbie Gernhardt (Admission), Shelley Kendall (Physical Plant), Jeff Moyers (College Relations), Peter Thayer (Library) and Ryan Zundell (College Relations).
10-year awards: Harry Baker (Physical Plant), Dawn Carusi (Communications), David Jeffery (Geology), Bonita Lowe (Physical Plant), Cathy Mowrer (Education), Tom Perry (College Relations), Mike Robinson (Information Technology), Mark Theobald (Physical Plant) and Natalie Wood (Career Center).
5-year awards: Tabatha Armstrong (Physical Plant), Ted Barth (Physical Plant), Wendy Bartlett (Geology), Ann Bragg (Physics), Andrew Bucheit (Athletics), Amanda Cech (Academic Resource Center), Jennifer Childers (Physician Assistant), Allison Eddleblute (Physical Plant), Jennifer Hancock (Biology), Lori Hart (Physician Assistant), Larry Hiser (Athletics), Billie Huck (Advancement), Hilles Hughes (Career Center), Nicole Livengood (English), Katie Lustofin (Biology), Drew Mohr (Athletics), Alane Sanders (Communications), Kemery Sigmund (Athletic Training), Gloria Stewart (Physician Assistant), Kara Tabor (Records), Josh Thrash (Admission), Bob VanCamp (Information Systems) and Jim Weaver (Campus Police).
The college will also recognize the six individuals – Mark Bagshaw (Business & Economics), Judy Dunn (Chemistry), Dave Gibbs (Physical Plant), Barb Hickman (Communications), Linda Meade (Physical Plant) and Gloria Stewart (Physician Assistant) – who are retiring in 2013.


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