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Adults with specific learning disorder have ongoing spelling problems sleep aid in nyquil buy provigil online from canada, slow and effortful reading sleep aid usa purchase discount provigil on-line, or problems making important inferences from numerical information in work-related written documents sleep aid use in pregnancy generic 100mg provigil. They may avoid both leisure and work-related activ ities that demand reading or writing or use alternative approaches to insomnia 35 weeks pregnant buy discount provigil on line access print. An alternative clinical expression is that of circumscribed learning difficulties that per sist across the lifespan, such as an inability to master the basic sense of number. Avoidance of or reluctance to engage in activi ties requiring academic skills is common in children, adolescents, and adults. Episodes of severe anxiety or anxiety disorders, including somatic complaints or panic attacks, are common across the lifespan and accompany both the circumscribed and the broader ex pression of learning difficulties. Prematurity or very low birth weight increases the risk for specific learning disorder, as does prenatal exposure to nicotine. Specific learning disorder appears to aggregate in families, particularly when affecting reading, mathematics, and spelling. The relative risk of spe cific learning disorder in reading or mathematics is substantially higher. Family history of reading diffi culties (dyslexia) and parental literacy skills predict literacy problems or specific learning disorder in offspring, indicating the combined role of genetic and environmental factors. There is high heritability for both reading ability and reading disability in alphabetic and nonalphabetic languages, including high heritability for most manifestations of learning abil ities and disabilities. Covariation between various manifestations of learning difficulties is high, suggesting that genes related to one presentation are highly correlated with genes related to another manifestation. Marked problems with inattentive behavior in preschool years is pre dictive of later difficulties in reading and mathematics (but not necessarily specific learn ing disorder) and nonresponse to effective academic interventions. Systematic, intensive, individualized instruction, using evidence-based interven tions, may improve or ameliorate the learning difficulties in some individuals or promote the use of compensatory strategies in others, thereby mitigating the otherwise poor out comes. Culture-Related Diagnostic issues Specific learning disorder occurs across languages, cultures, races, and socioeconomic conditions but may vary in its manifestation according to the nature of the spoken and written symbol systems and cultural and educational practices. For example, the cognitive processing requirements of reading and of working with numbers vary greatly across or thographies. In the English language, the observable hallmark clinical symptom of diffi culties learning to read is inaccurate and slow reading of single words; in other alphabetic languages that have more direct mapping between sounds and letters. In English-language learners, assessment should include con sideration of whether the source of reading difficulties is a limited proficiency with Eng lish or a specific learning disorder. Risk factors for specific learning disorder in Englishlanguage learners include a family history of specific learning disorder or language delay in the native language, as well as learning difficulties in English and failure to catch up with peers. Also, assessment should consider the linguistic and cultural context in which the individual is living, as well as his or her educational and learning history in the original culture and language. Gender-Related Diagnostic issues Specific learning disorder is more common in males than in females (ratios range from about 2:1 to 3:1) and cannot be attributed to factors such as ascertainment bias, definitional or measurement variation, language, race, or socioeconomic status. Functionai Consequences of Specific Learning Disorder Specific learning disorder can have negative functional consequences across the lifespan, including lower academic attainment, higher rates of high school dropout, lower rates of postsecondary education, high levels of psychological distress and poorer overall mental health, higher rates of unemployment and under-employment, and lower incomes. School dropout and co-occurring depressive symptoms increase the risk for poor mental health outcomes, including suicidality, whereas high levels of social or emotional support predict better mental health outcomes. Specific learning disorder is distinguished from normal variations in academic attainment due to external factors. Specific learning disorder differs from general learning difficulties associated with intellectual disability, because the learning difficulties occur in the presence of normal levels of intellectual functioning. If intellectual disability is present, specific learning disorder can be diagnosed only when the learning difficulties are in excess of those usually associated with the intellectual disability. Specific learning dis order is distinguished from learning difficulties due to neurological or sensory disorders. Specific learning disorder is distinguished from learning problems associated with neurodegenerative cognitive disorders, because in specific learning disorder the clinical expression of specific learning difficulties occurs during the developmental period, and the difficulties do not manifest as a marked decline from a for mer state. Specific learning disorder is distinguished from the academic and cognitive-processing difficulties associated with schizophrenia or psychosis, because with these disorders there is a decline (often rapid) in these functional domains. Comorbidity Specific learning disorder commonly co-occurs with neurodevelopmental. These comorbidities do not necessarily exclude the diagnosis specific learning disorder but may make testing and differential diagnosis more difficult, because each of the co occurring disorders independently interferes with the execution of activities of daily liv ing, including learning. Thus, clinical judgment is required to attribute such impairment to learning difficulties. If there is an indication that another diagnosis could account for the difficulties learning keystone academic skills described in Criterion A, specific learning disorder should not be diagnosed. The acquisition and execution of coordinated motor skills is substantially below that ex pected given the individual’s chronological age and opportunity for skill learning and use. The motor skills deficit in Criterion A significantly and persistently interferes with activ ities of daily living appropriate to chronological age. The motor skills deficits are not better explained by intellectual disability (Intellectual devel opmental disorder) or visual impairment and are not attributable to a neurological condi tion affecting movement. Diagnostic Features the diagnosis of developmental coordinahon disorder is made by a clinical synthesis of the history (developmental and medical), physical examination, school or workplace report, and individual assessment using psychometrically sound and culturally appropriate standardized tests. The manifestation of impaired skills requiring motor coordination (Criterion A) varies with age. They also may be delayed in de veloping skills such as negotiating stairs, pedaling, buttoning shirts, completing puzzles, and using zippers. Even when the skill is achieved, movement execution may appear awkward, slow, or less precise than that of peers. Older children and adults may display slow speed or in accuracy with motor aspects of activities such as assembling puzzles, building models, playing ball games (especially in teams), handwriting, typing, driving, or carrying out self-care sldlls. Developmental coordination disorder is diagnosed only if the impairment in motor skills significantly interferes with the performance of, or participation in, daily activities in family, social, school, or community life (Criterion B). Examples of such activities include getting dressed, eating meals with age-appropriate utensils and without mess, engaging in physical games with others, using specific tools in class such as rulers and scissors, and participating in team exercise activities at school. Not only is ability to perform these ac tions impaired, but also marked slowness in execution is common. Handwriting compe tence is frequently affected, consequently affecting legibility and/or speed of written output and affecting academic achievement (the impact is distinguished from specific learning difficulty by the emphasis on the motoric component of written output skills). In adults, everyday skills in education and work, especially those in which speed and accuracy are required, are affected by coordination problems. Criterion C states that the onset of symptoms of developmental coordination disorder must be in the early developmental period. However, developmental coordination disorder is typically not diagnosed before age 5 years because there is considerable variation in the age at acquisition of many motor skills or a lack of stability of measurement in early childhood. Criterion D specifies that the diagnosis of developmental coordination disorder is made if the coordination difficulties are not better explained by visual impairment or at tributable to a neurological condition. Thus, visual function examination and neurological examination must be included in the diagnostic evaluation. Developmental coordination disorder does not have discrete subtypes; however, indi viduals may be impaired predominantly in gross motor skills or in fine motor skills, in cluding handwriting skills. Other terms used to describe developmental coordination disorder include childhood dyspraxia, specific developmental disorder of motorfunction, and clumsy child syndrome. Associated Features Supporting Diagnosis Some children with developmental coordination disorder show additional (usually sup pressed) motor activity, such as choreiform movements of unsupported limbs or mirror movements. These "overflow" movements are referred to as neurodevelopmental immaturities or neurological soft signs rather than neurological abnormalities. In both current literature and clinical practice, their role in diagnosis is still unclear, requiring further evaluation. Prevaience the prevalence of developmental coordination disorder in children ages 5-11 years is 5%6% (in children age 7 years, 1. Males are more of ten affected than females, with a maleifemale ratio between 2:1 and 7:1. Development and Course the course of developmental coordination disorder is variable but stable at least to 1 year follow-up. Although there may be improvement in the longer term, problems with coor dinated movements continue through adolescence in an estimated 50%-70% of children. Delayed motor milestones may be the first signs, or the disor der is first recognized when the child attempts tasks such as holding a knife and fork, but toning clothes, or playing ball games. In middle childhood, there are difficulties with motor aspects of assembling puzzles, building models, playing ball, and handwriting, as well as with organizing belongings, when motor sequencing and coordination are re quired. In early adulthood, there is continuing difficulty in learning new tasks involving complex/automatic motor skills, including driving and using tools. Inability to take notes and handwrite quickly may affect performance in the workplace.
Building on the initial literature reviews insomnia 2 hours a night buy generic provigil 200mg online, work groups identified key issues within their diagnostic areas insomnia first trimester order generic provigil canada. New diagnoses and disorder subtypes and specifiers were sub ject to sleep aid mouthpiece discount provigil 200mg amex additional stipulations insomnia 75 mg purchase generic provigil line, such as demonstration of reliability. Dis orders with low clinical utility and weak validity were considered for deletion. Stratified samples of four to seven specific disorders, plus a stratum containing a representative sample of all other diagnoses, were identified for each site. Patients consented to the study and were randomly assigned for a clinical interview by a cli nician blind to the diagnosis, followed by a second interview with a clinician blind to previous diagnoses. Patients first filled out a computer-assisted inventory of cross-cutting symptoms in more than a dozen psychological domains. These inventories were scored by a central server, and results were provided to cliniciais before they conducted a typical clinical interview (with no structured protocol). This study design allowed the calculation of the degree to which two independent clinicians could agree on a diagnosis (us ing the intraclass kappa statistic) and the agreement of a single patient or two different clini cians on two separate ratings of cross-cutting symptoms, personality traits, disability, and diagnostic severity measures (using intraclass correlation coefficients) along with information on tiie precision of these estimates of reliability. The routine clinical practice field trials involved recruitment of individual psychiatrists and other mental health clinicians. A volunteer sample was recruited that included gener alist and specialty psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, and advanced practice psychiatric mental health nurses. All draft diagnostic criteria and proposed changes in organization were posted on Feedback totaled more than 8,000 submis sions, which were systematically reviewed by each of the 13 work groups, whose members, where appropriate, integrated questions and comments into discussions of draft revisions and plans for field trial testing. After revisions to the initial draft criteria and proposed chapter organization, a second posting occurred in 2011. The preparation of the text was coordinated by the text editor, working in close collaboration with the work groups and under the direction of the task force chairs. Each proposal for diagnostic revision required a memorandum of evidence for change pre pared by the work group and accompanied by a summary of supportive data organized around validators for the proposed diagnostic criteria. Work groups also added forensic experts as advisors in pertinent areas to complement expertise pro vided by the Council on Psychiatry and Law. The work groups themselves were charged with the responsibility to review the entire re search literature surrounding a diagnostic area, including old, revised, and new diagnostic cri teria, in an intensive 6-year review process to assess the pros and cons of making either small iterative changes or major conceptual changes to address the inevitable reification that occurs with diagnostic conceptual approaches that persist over several decades. Such changes in cluded the merger of previously separate diagnostic areas into more dimensional spectra, such as that which occurred with autism spectrum disorder, substance use disorders, sexual dys functions, and somatic symptom and related disorders. Other changes included correcting flaws that had become apparent over time in the choice of operational criteria for some disor ders. Furthermore, many of these major changes were subject to field trial testing, although comprehensive testing of all proposed changes could not be accommo dated by such testing because of time limitations and availability of resources. The many experts, reviewers, and advisors who contributed to this process are listed in the Appendix. These criteria have been subjected to scientific review, albeit to varying degrees, and many disorders have un dergone field testing for interrater reliability. Although the need for reform seemed apparent, it was important to respect the state of the science as well as the chal lenge that overly rapid change would pose for the clinical and research communities. In that spirit, revision of the organization was approached as a conservative, evolutionary di agnostic reform that would be guided by emerging scientific evidence on the relationships between disorder groups. By reordering and regrouping the existing disorders, the re vised structure is meant to stimulate new clinical perspectives and to encourage research ers to identify the psychological and physiological cross-cutting factors that are not bound by strict categorical designations. However, it should be noted that these diagnostic criteria and their relationships within the classification are based on current research and may need to be modified as new evidence is gathered by future research both within and across the do mains of proposed disorders. These diagnostic criteria are included to highlight the evolution and direction of scientific advances in these areas to stimulate further research. With any ongoing review process, especially one of this complexity, different viewpoints emerge, and an effort was made to consider various viewpoints and, when warranted, ac commodate them. As this field evolves, it is hoped that both versions will serve clin ical practice and research initiatives. Early in the course of the revisions, it became apparent that a shared organizational structure would help harmonize the classifications. Of course, principled disagreements on the classification of psychopathology and on specific criteria for certain disorders were expected given the current state of scientific knowledge. To the surprise of participants in both revision processes, large sections of the content fell relatively easily into place, reflecting real strengths in some areas of the scientific lit erature, such as epidemiology, analyses of comorbidity, twin studies, and certain other ge netically informed designs. When disparities emerged, they almost always reflected the need to make a judgment about where to place a disorder in the face of incomplete—or, more often, conflicting—data. The work groups recognize, however, that future dis coveries might change the placement as well as the contours of individual disorders and, furthermore, that the simple and linear organization that best supports clinical practice may not fully capture the complexity and heterogeneity of mental disorders. These codes will not be in sequential order throughout the manual because they were assigned to complement earlier organizational structures. Relevant evidence comes from diverse sources, including shidies of comorbidity and the substantial need for not otherwise specified diagnoses, which repre sent the majority of diagnoses in areas such as eating disorders, personality disorders, and autism spectrum disorder. Indeed, the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow di agnostic categories that did not capture clinical reality, symptom heterogeneity within dis orders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are het erogeneous at many levels, ranging from genetic risk factors to symptoms. Eleven such indicators were recommended for this purpose: shared neural sub strates, family traits, genetic risk factors, specific environmental risk factors, biomarkers, temperamental antecedents, abnormalities of emotional or cognitive processing, symptom similarity, course of illness, high comorbidity, and shared treatment response. These indi cators served as empirical guidelines to inform decision making by the work groups and the task force about how to cluster disorders to maximize their validity and clinical utility. A series of papers was developed and published in a prominent international journal (Psychological Medicine, Vol. Within both the internalizing group (representing disorders with prominent anxiety, depressive, and somatic symptoms) and the externalizing group (representing disorders with prominent impulsive, disruptive conduct, and substance use symptoms), the sharing of genetic and environmental risk factors, as shown by twin studies, likely explains much of the system atic comorbidities seen in both clinical and community samples. The adjacent placement of "internalizing disorders," characterized by depressed mood, anxiety, and related physio logical and cognitive symptoms, should aid in developing new diagnostic approaches, in cluding dimensional approaches, while facilitating the identification of biological markers. Similarly, adjacencies of the "externalizing group," including disorders exhibiting antiso cial behaviors, conduct disturbances, addictions, and impulse-control disorders, should en courage advances in identifying diagnoses, markers, and underlying mechanisms. The organizational structure is meant to serve as a bridge to new diagnostic approaches with out disrupting current clinical practice or research. It begins with diagnoses thought to reflect developmental processes that manifest early in life. This organizational structure facili tates the comprehensive use of lifespan information as a way to assist in diagnostic deci sion making. It is hoped that this organization will encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity. Cultural Issues Mental disorders are defined in relation to cultural, social, and familial norms and values. Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, re vised, and recreated within the family and other social systems and institutions. In the Appendix, the "Glossary of Cultural Concepts of Distress" provides a description of some common cul tural syndromes, idioms of distress, and causal explanations relevant to clinical practice. The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cul tures, social settings, and families. Hence, the level at which an experience becomes prob lematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians. Awareness of the significance of culture may correct mistaken interpretations of psychopathology, but cul ture may also contribute to vulnerability and suffering. Cultural meanings, habits, and traditions can also contribute to either stigma or support in the social and familial response to mental illness. Culture may provide coping strategies that enhance resilience in response to illness, or sug gest help seeking and options for accessing health care of various types, including alterna tive and complementary health systems. Culture may influence acceptance or rejection of a diagnosis and adherence to treatments, affecting the course of illness and recovery.
A clean environment is also a 235 basic expectation of clients/patients/residents xanax sleep aid dosage buy provigil 200 mg lowest price, their families insomnia pregnancy cheap 100mg provigil mastercard, and staff sleep aid gabapentin order provigil cheap online, and is essential to sleep aid hypnosis order provigil 200 mg otc providing a 236 patientand family-focused care environment and a positive work environment. Sufficient resources must be devoted to environmental services to ensure effective cleaning at all times, including surge capacity for high-demand periods. Supervisors with responsibility for ensuring adherence to occupational health and infection prevention and control policies and protocols, including the correct use of personal protective equipment, maintaining a safe work environment, and ensuring adherence to cleaning schedules and protocols. Contract staff must work collaboratively with clinical staff, infection prevention and control, and occupational health and safety to ensure the safety of clients/patients/residents, staff and visitors; contractual barriers that prevent this from happening 242 should be removed. A variety of approaches have been taken to estimate average cleaning times that include basing estimates on past experience, conducting time/motion studies, adding up the 249 250 time required for a series of individual tasks, or using industry standards or workload software. Currently, the best method for determining average cleaning times, and therefore appropriate staffing 249,251 levels, is unknown. Supervisory staff has 229 responsibilities under the Occupational Health and Safety Act to ensure staff training and compliance when using personal protective equipment. All clinical areas require a “health care clean” in addition to a “hotel clean” (which is also still required). This risk assessment could be integrated with an assessment of the required frequency of cleaning, as discussed in Section 3. A health care clean should result in the elimination of, or a significant reduction in, microbial contamination of all surfaces and items within the environment, in addition to providing a visually clean environment. The health care component of a health care facility includes all areas involved in client/patient/resident care including all client/patient/resident wards or units and including nursing stations; procedure rooms; clinic and examination rooms; diagnostic and treatment areas; and washrooms*. Areas that require a health care clean should have different cleaning protocols and additional environmental service human resources that are sufficient to allow the more intensive and frequent cleaning (and monitoring of cleaning) required for these areas. Components of Hotel Clean • Floors and baseboards are free of stains, visible dust, spills and streaks. Note: Frequency of health care clean is determined according to the Risk Stratification Matrix in Appendix 21: Risk Stratification Matrix to Determine Frequency of Cleaning 3. The 278-282 specific surfaces that should be considered high-touch will vary between health care settings. Areas should be considered moderately contaminated if surfaces or equipment are regularly contaminated with blood or body fluids. When determining the appropriate frequency of cleaning and disinfection, the following principles apply: fi High-touch surfaces and items require more frequent cleaning and disinfection than low-touch surfaces and items. Using these criteria, each area or department in a health care setting can be evaluated and assigned a risk score for cleaning purposes, as illustrated in Appendix 21. Noncritical medical equipment that is within the client/patient/resident’s environment and used between clients/patients/residents. The health care setting should have written policies and procedures for the appropriate cleaning and disinfection of equipment that clearly define the frequency and level of cleaning and assign responsibility for cleaning. Education All aspects of environmental cleaning must be supervised and performed by knowledgeable, trained staff. Education on the topics of infection prevention and control and of occupational health and safety should be provided at the initiation of employment as part of the orientation process and as ongoing continuing 8,79,219,220,229,242,294,295 education. In addition, environmental service workers should be aware of: fi Work restrictions including the need to avoid working in client/patient/resident areas when ill 31,243,305 with a known or suspected communicable infection. Contracts with supplying agencies should include the above immunizations for contracted staff. Exposures occur most commonly via inhalation 145 (respiratory) or direct skin contact. Respiratory symptoms increase in direct proportion to increased exposure time and higher concentrations of certain 317 chemicals, such as bleach and ammonia. Exposure to workplace chemicals may be reduced through the use of engineering controls. Facilities should periodically conduct an occupational hazards assessment with respect to cleaning and disinfection of surfaces and equipment. Repetitive movements, awkward work postures, heavy lifting, and application of high forces. Each client/patient/resident care area should be equipped with a room dedicated as a soiled utility room that may be used to clean soiled patient/resident 340 equipment that is not sent for central reprocessing. To facilitate this, facilities shall have a sufficient number of rooms that are dedicated to the storage of cleaning equipment and supplies required for daily cleaning 80,340,341 (housekeeping closets) and are located conveniently throughout the facility. These rooms are 80,341 used for the storage, preparation and disposal of cleaning supplies and equipment, and are distinct from the clean utility/supply rooms described in 6. Facilities may also have centralized housekeeping rooms for storing bulky cleaning equipment and large 80,341 volume of supplies for distribution to local areas. At a minimum, there shall be at least one 80,340 housekeeping closet in all major care areas. In addition, housekeeping closets: fi Must be dedicated for use as a cleaning supply room where cleaning solution is prepared, and 80,341 dirty cleaning solution is disposed; and must not be used for other purposes. This should be done as frequently as is necessary to avoid accumulation of dust and dispersion of dust to other areas of the facility, and at least daily. Where there is transport of construction materials (both clean and used materials) through the health care setting, a clear plan for traffic flow 86 that bypasses care areas as much as possible shall be established and adhered to. Responsibility for construction clean and hotel/health care clean must be clearly defined within the health care setting: Components of Construction Clean Performed by construction workers inside the construction zone/hoarding: • Floors are swept to remove debris. Until confirmed as a clean water source, all staff should assume that the water is contaminated. Regardless of the water source, the area will need to be cordoned off until cleaning and disinfection are completed. Persistent moisture following floods can lead to mould growth on plaster, drywall, carpeting and 124 86 furnishings. If the flooding involves a food preparation area, all food products that have come into contact with water must be discarded and the public health unit notified. Clean water Broken pipes, tub overflows, sink overflows, many Allow materials to dry appliance malfunctions, falling rainwater, broken completely before use. Shall have appropriate personal protective equipment available, including safety eyewear. Shall have chemical storage that ensures chemicals are not damaged and may be safely accessed. Environmental microorganisms are the most frequently implicated, including Bacillus cereus and environmental fungi. Such outbreaks have been caused by errors in the washing process, contamination 347 during post-cleaning transportation and inappropriate storage conditions. In addition to outbreaks affecting patients, exposure of staff to harmful microorganisms can occur if soiled linens are not handled appropriately. In most staff exposures, failure to use appropriate personal protective equipment and/or inappropriate sorting of linens resulting in aerosolization contributed to 351-353 the transmission of microorganisms. If their use is unavoidable, ensure that they are properly 304 designed, maintained, cleaned, disinfected, and used in a manner that minimizes dispersion 92,218 of aerosols from contaminated laundry: • Ensure that laundry bags are securely bagged and tightly closed before placing the filled bag 3,92 into the chute. Special handling of linen for clients/patients/residents on Additional Precautions is not 92,218,358 routinely required. Laundered items should be taken out of the washer as soon 92,347 as feasible to reduce the risk of contaminating the washer and formation of biofilm. There should be 3,92 posted instructions on washing and drying patient/resident laundry. It is estimated that about 60% of the waste generated by a health care facility is general (nonhazardous) waste, about one-third of the 361 waste is recyclable (including compost), and biomedical waste constitutes only about 7% of all waste. This will reduce the amount of waste categorized as biomedical and subsequently going for incineration or land disposal. In addition, they should be appropriate for the nature of the waste being collected. For waste from patients of viral hemorrhagic fevers, see: fi Ontario Agency for Health Protection and Promotion (Public Health Ontario). In Ontario, all health care settings are required to use safety-engineered needles, according to the Needle Safety Regulation, O. A procedure for safely disposing of a contaminated sharp that has not been correctly disposed of may be found in Appendix 26. For details on the classification, packaging, documentation and training requirements for shipping infectious substances, see fi Transport Canada’s Transportation of Dangerous Goods Bulletin: Shipping Infectious Substances.
Uncontroversially insomnia lyrics audien order provigil with mastercard, the bombing preceded the ethnic cleansing and atrocities insomnia yelp buy provigil mastercard, which were sleep aid jitters order provigil paypal, in fact sleep aid trip order discount provigil on-line, its anticipated consequence. These basic facts were well known by May 1999, when the Milosevic indictment was presented; it detailed a series of terrible crimes, which had, however, virtually without exception taken place after the bombing. But since Western documentation reveals no notable change in the distribution of violence after Racak, their conclusions, if valid in mid-January, essentially remained so in late March. Thus, the Liquica massacre in East Timor shortly after was apparently far worse, was only one of many, and had no pretext of Noam Chomsky 31 Hegemony or Survival self-defense. Putting aside such selective concerns, however, the voluminous Western evidence does not reveal any significant shift in Kosovo before the bombing. Nevertheless, he concludes that bombing Serbia was a genuine case of humanitarian intervention because "though only a few hundred Albanians were killed" prior to the bombing, "intelligence points to this as a precursor to a major campaign of killing and ethnic cleansing. Andrew Bacevich gives an even more cynical interpretation, dismissing all humanitarian motives. What counted was "affirming the dominant position of the United States in a Europe that was unified, integrated, and open. With these norms established, it becomes legitimate to invade Noam Chomsky 32 Hegemony or Survival a country without Security Council authorization. As approvingly noted by the dean of the Woodrow Wilson School of Public and International Affairs at Princeton, "That is the lesson that the United Nations and all of us should draw" from the invasion of Iraq, firmly grounded in the new norms. These are the crucial lessons, and those concerned with the future would be well advised to take them seriously. Atrocities in Colombia include displacement of the population through chemical warfare (called "fumigation") under the guise of a drug war that is hard to take seriously. Meanwhile the land is poisoned by fumigation, children die, and the uprooted and scattered victims suffer from sickness and injury. Peasant agriculture is based on a rich tradition of knowledge and experience gained over many centuries, commonly passed on from mother to daughter. Though a remarkable human achievement, it is very fragile and can be destroyed forever in a single generation. It is being destroyed, and along with it, some of the richest biodiversity in the world. Campesinos, indigenous people, and Afro-Colombians are now joining the millions in rotting slums and camps. And with the people gone, multinationals can strip the mountains for coal, extract oil and other resources, and probably convert what is left of the land to ranching by the rich or agroexport in an environment shorn of its treasures and variety. Like many other centers of turmoil and state terror, Colombia is part of an important oil-producing region, and a significant producer itself: much the same is true of Chechnya, Western China, the Central Asian dictatorships, and other places where state violence was intensified after 9-11 on the pretext of a "war on terror," and with the expectation that there would be a nod from Washington. Noam Chomsky 33 Hegemony or Survival Human rights organizations and the State Department agree that the overwhelming majority of atrocities in Colombia can be attributed to the military and paramilitaries, the "sixth division" of the five-division Colombian army, because of their close links, according to Human Rights Watch. The proportion of atrocities attributed to the paramilitaries has been increasing as crimes are privatized in accord with neoliberal practice, a familiar development elsewhere as well: Serbia used private militias in the former Yugoslavia, as did Indonesia in East Timor, and Turkey in the southeast, and many other places. Imagine the reaction to a proposal that Colombia or China should undertake fumigation programs in North Carolina to destroy government-subsidized crops used for more lethal products —which, furthermore, they not only must import at risk of trade sanctions, but for which they must allow advertising aimed at vulnerable populations. There is a new and highly regarded literary genre inquiring into the cultural defects that keep us from responding properly to the crimes of others. An interesting question no doubt, though by any reasonable standard it ranks well below a different one: Why do we persist in our own crimes, either directly or through crucial support for murderous clientsfi It is instructive to ask how often, or how accurately, one finds reference to Turkey, Colombia, East Timor, and many similar examples in the contemporary literature on the flaws in our character. As before, the most that can be said is that we "tolerated" the abuses suffered by the Kurds (Aryeh Neier). Their easy acceptance in the most powerful state in history again does not bode well for the future. Another currently fashionable formulation of the mission of the enlightened states holds that "the need. One of these Robert Jervis calls a "change of spectacular proportions, perhaps the single most striking discontinuity that the history of international politics has anywhere provided": that the states of Europe now live in peace— and, some argue more controversially, democracies do not go to war with one another. Protecting Naughty Children from Infection the enlightened states of the late nineteenth century were not the first to laud themselves for liberating barbarians from their sad fate—by violence, destruction, and plunder. They were drawing from a rich tradition of distinguished leaders who were troubled by the rising "flood of evil doctrines and pernicious examples" and asked "what would become of our religious and political institutions, of the moral force of our governments, and of that conservative system which has saved [us] from complete dissolution [if] the contagion and the invasion of vicious principles" is not deterred or overcome. In expressing these concerns, the Czar and Metternich were referring to "the pernicious doctrines of republicanism and popular self-rule [spread by] the apostles of sedition" in the New World—in the rhetoric of contemporary planners, a rotten apple that might spoil the barrel, a domino that might topple others. The contagion of these doctrines, they warned, "crosses the seas, and often appears with all the symptoms of destruction which characterize it, in places where not even any direct contact, any relation of proximity might give ground for apprehension. While this may seem based on selfishness alone, the author of the Doctrine had no higher or more generous motive in its declaration. The story continues right to the front pages of 2003, with enormous poverty in a country of rich resources and potential, yielding great wealth to foreign investors and a small sector of the population. It may be useful to "pat them a little bit and make them think that you are fond of them," Secretary of State John Foster Dulles advised President Eisenhower. Wilson regarded Filipinos as "children [who] must obey as those who are in tutelage"— at least, those who survived the liberation he had called for while extolling his altruism. His State Department also regarded Italians as "like children [who] must be [led] and assisted more than almost any other nation. The coup sent a more far-reaching message, spelled out by the editors of the New York Times: "Underdeveloped countries with rich resources now have an object lesson in the heavy cost that must be paid by one of their number which goes berserk with fanatical nationalism. Latin Americans were then under the influence of what the State Department called "the philosophy of the New Nationalism, [which] embraces policies designed to bring about a broader distribution of wealth and to raise the standard of living of the masses. It is useful to recall that even at the peak of the Cold War more perceptive observers understood that the primary threat posed by Communism was the economic transformation of the Communist countries "in ways that reduce their willingness and ability to complement the industrial economies of the West," another version of "the philosophy of the new nationalism," in this case dating from 1917. The "analytical framework" of relations with the fascist states is eminently worth recalling, if only because it has reappeared with such consistency right to the present and therefore can teach us a good deal about the world that has been shaped in no small measure by the most powerful states and the private institutions that are their "tools and tyrants," to borrow the words of James Madison when he contemplated with much unease the fate of the democratic experiment of which he was the leading framer. The reason was that the fascist version of extreme nationalism permitted extensive Western economic penetration and also destroyed the much-feared labor movements and the left, and the excessive democracy in which they could function. A decade later, in 1937, the State Department continued to regard European fascism as a moderate force that "must succeed or the masses, this time reinforced by the disillusioned middle classes, will again turn to the Left. As noted earlier, Welles felt that it "presented the opportunity for the establishment by the nations of the world of a new world order based upon justice and upon law," in which the Nazi moderates would play a leading role. In April 1941, George Kennan wrote from his consular post in Berlin that German leaders have no wish to "see other people suffer under German rule," are "most anxious that their new subjects should be happy in their care," and are making "important compromises" to assure this benign outcome. Investment boomed in Fascist Italy; "the wops are unwop-ping themselves," Fortune magazine declared in 1934. After the rise of Hitler, investment boomed in Germany for similar reasons: a stable climate had been established for business operations, with the threat of "the masses" contained. Until war broke out in 1939, Scott Newton writes, Britain was even more supportive of Hitler, for reasons deeply rooted in Anglo-German industrial, commercial, and financial relations, and "a policy of self-preservation for the British establishment" in the face of rising popular democratic pressures. Throughout, policy planners have faced the "agonizing problem" of how to reconcile a formal commitment to democracy and freedom with the overriding fact that "the United States may often need to do terrible things to get what it has always wanted," Alan Tonelson observes. Secretary of State Lansing warned President Wilson that the Bolshevik disease might spread, "a very real danger in view of the process of social unrest throughout the world. Business leaders remained alert to "the hazard facing industrialists [with] the newly realized political power of the masses" and the constant need for shaping public opinion "if we are to avoid disaster. The Cold War itself from its origins in 1917 was in significant respects a "North-South" conflict writ large. Russia was a special case because of its scale and military power, a factor of growing importance after it played the leading role in defeating Nazi Germany and achieved superpower status in the military dimension. But the primary threats remained as they have been throughout the non-Western World: independent nationalism and the virus effect. The illogicality they perceived dissolves as soon as we realize that the Soviet Union might have "flirted with the thought" of associating itself with "a rising tide all over the world wherein the common man aspires to higher and wider horizons. Attack is therefore defense, another "logical illogicality" that becomes coherent once the doctrinal apparatus is properly understood. Note that the defensive invasion of Russia in 1918 is another precursor for the doctrine of preventive war declared in September 2002 by radical nationalists pursuing their imperial vision. By 1945 they realized that the game was over: the next time it was played would be the last. Western powers can still resort to violence against the weak and defenseless, but not against one another. The Cold War superpower conflict, too, kept to that understanding, though not without extreme hazard. The standard interpretation is different: the "democratic peace" reflects "some happy combination of liberal norms and institutions such as representative democracy and market economies.
In recent years insomnia essential oil recipes purchase provigil from india, interest in a systematic study of these problems has heightened considerably sleep aid research cheap 100 mg provigil amex. This increase of interest can be at-52tributed to sleep aids that work generic provigil 100 mg amex converging influences coming from three major sources sleep aid cat purchase provigil 200mg visa. The first of these sources has been the rapid pace of development in several scientific disciplines. Advances in neurophysiology have led to a gradual revision in our conception of the nervous system and have produced data that provide changing physiological models for psychological events (37). There are now available increasingly sophisticated electrophysiological methods of measuring neural function at various levels of the nervous system. Recent reports (29, 61) have demonstrated electrical changes in the central nervous system followfag reduced sensory input. Neurochemistry has begun to provide techniques for evaluating the nature of these consequences. Psychoanalysis is another discipline in which interest in these issues is growing. Here, increasing emphasis is placed on the importance of understanding ego functioning and its role in mediating behavior. From this viewpoint, the question may be raised, "If the ego is the executive aspect of personality, enabling the individual to cope with reality, what becomes of ego functions in the absence of an external environment with which to copefi The work of Hartmann (36) in elaborating the theoretical basis of "ego psychology" is important in this development. A second major source of interest in human response to restricted environments has come from the military establishment. Technological developments, as seen in a variety of military applications, have given the pursuit of these questions a new urgency. With the advent of space craft, isolated radar stations, and a generally increased reliance on automated equipment, the problem of efficient functioning in severely restricted, monotonous environments is no longer merely of theoretical or academic interest. The problem of efficient personnel selection and utilization, in a wide variety of these circumstances, has provided marked impetus to the initiation and development of research programs dealing with reactions to limited sensory and social environments. In this connection, the experience of prisoners of war with Communist "thoughtreform" has had similar effects. The revelation that isolation may be one factor in the susceptibility of humans to radical changes in customary behavior and beliefs has heightened interest in the study of isolation. The shocked fascination of the general public, not excepting the scientific community, has served to highlight the need for a systematic understanding of the effects of physical and 53social isolation on behavior. Literature on methods of "thoughtreform" or ideological reform has attempted to place these procedures in a context which emphasizes the fact that they are well known and not the result of new discoveries or magical innovations on the part of the Communists (9, 10, 42, 49, 67). In these procedures, solitary confinement and monotonous, barren surroundings play an important role in making the prisoner more receptive and susceptible to the influence of the interrogator. The use of this technique rests not on laboratory science but is part of the empirical know-how of police and military interrogation. A third major source of interest in these phenomena, although perhaps less dramatic than the foregoing, has come from developments within academic psychology. One such development has taken place in the area of motivation, in which a number of experimenters (14, 34, 58) have attempted to establish the existence and operation of what has been called curiosity or exploratory drive as a primary motive. Attributing a significant role in the determination of behavior to such a drive, we find that this research has arisen in a context which seeks to refute the strongly prevalent view of the organism as a passive receptacle of experience; one which responds only to driverelevant stimulation. As formulated by Hebb, "Characteristically, stimulus response theory has treated the animal as more or less inactive unless subject to special conditions of arousal. Studying human response to restricted environments may indicate the mode of operation of the "need for experience. Studies of sensory deprivation early in the life of animals, and the effects upon subsequent development and learning, have a relatively long history within psychology. Originally designed to evaluate the relative influence of innate organizational processes (as opposed to learning) on perception, these researches have since been more directly focused on the general effects of early deprivation upon a variety of subsequent behaviors. Although experimental work, because of ethical considerations, has of necessity been confined to animal investigations, clinical and anecdotal evidence such as the reports of Spitz (73, 74, 75) and others (22, 23, 26, 27), and those on "feral man" (70, 71) have supplemented these studies. These reports 54have highlighted the importance of a full range of early environmental experience to the development of normal adult functioning. The occurrence of serious and irreversible disruptions of normal development and behavior has been reported. Methodological Considerations Before turning to an examination of the experimental findings, it may be well to consider some of the methodological and conceptual problems raised by research in this area. The diversity of variables involved in a systematic study of response to reduced environmental stimulation makes for considerable complexity. It will be useful to take a brief overview of procedures employed by various investigators. In the first of these, efforts were directed toward an absolute reduction of input to the organism from the external world. Lilly (50) immersed two subjects up to three hours in a tank of slowly circulating tepid water, wearing nothing but a head mask that covered eyes and ears. Subjects received an initial set of training exposures to overcome fear of the situation. On the day of the experiment, they were placed in the tank and were instructed to inhibit all movement so far as possible. Although absolute reduction in sensory input is the goal here, this latter method places less of a restriction on motor activity. A second approach to reducing sensory stimulation was used by Bexton, Heron and Scott (8). They reduced patterning of sensory inputwhile retaining levels of input at near normal. In this procedure using twenty-two male college students, the subject wore a pair of translucent goggles that permitted the perception of light but not of objects. Auditory input consisted of the masking sound of fan and airconditioner motors, and tactile experience was reduced through the use of cuffs and gloves that permitted no direct exploration of the immediate surroundings. In this procedure goggles are not used and the subject is exposed to normally patterned vision of a highly restricted environment. Wexler, Mendelson, Leiderman, and Solomon (80) placed seventeen subjects into polio tank respirators with arms and legs in cardboard cuffs. The repetitive drone of the respirator motor provided an auditory masking sound, whereas the visual environment consisted of the front of the respirator and the blank walls of a screen. Since the ports of the respirator were left open, subjects breathed for themselves. This procedure relies on monotony to achieve its effects and is thus similar to situations in which highly repetitive simple tasks are performed. It is also most similar to the environment of the prisoner in solitary confinement as well as other isolation situations as encountered in real life. Without attempting a comprehensive survey of methodological problems and issues, some examination of the choices confronting researchers in this problem area may be helpful. Efforts at the absolute reduction of sensory input are limited by the impossibility completely of doing away with sensory experience in a living conscious organism. Even the most sophisticated instrumentation cannot eliminate sensations and perceptions arising from internal body functions. To the extent to which this goal is relevant to testing a variety of hypotheses, it can only be approximated. Few if any investigators have attempted a rigorous definition of the terms they have employed. Most have used their experimental methods to provide an empirical basis for their conceptions. Indeed it is understandable that the number of descriptive terms and phrases in the literature is almost as large as the number of investigators. Without becoming too deeply embroiled in the sensation-perception issue, it may be useful to think of attempts at the absolute reduction of intensity of input to the organism as sensory deprivation, whereas reduced patterning and monotony may be more meaningfully seen as perceptual deprivation. The outstanding characteristic of the latter two approaches appears to be the decrease in the structure and variety of input. The term "isolation" is one which seems to be relevant to the social dimension rather than to the sensory and perceptual aspects of the various experimental conditions employed. At this stage of 56our knowledge, it is unclear as to whether there are different behavioral consequences of sensory as opposed to perceptual deprivation, in the sense used above.
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