Clinical Assessment - Science topic

might there be copyright issues with established tests. You need to state were items are collected (source for each item)

Certainly, there are several reputable websites and online resources dedicated to providing comprehensive details on clinical-based research. Here are some notable websites:

PubMed Central (PMC), ClinicalTrials.gov, Cochrane Library, Cochrane Library, The NIH website, UpToDate, European Medicines Agency (EMA), American College of Physicians (ACP), JAMA Network, BMJ (British Medical Journal), The WHO International Clinical Trials Registry Platform (ICTRP), among others.

Remember to critically evaluate the sources and consider the context and methodology of the studies you find on these platforms. Always consult with peers and experts in the field to ensure the validity and relevance of the information you gather.

Try Depression and Anxiety Scales 21 items. DASS 21

Free Assessment Portal

How to Navigate the Skillworx Africa Assessment Portal

Skeletal Muscle structure, function and plasticity by @RichardLieber

Mutasem Z. Bani-Fwaz Good question

Childhood trauma questionnaire : a retrospective self-report : manual

Author:David P Bernstein; Laura Fink Publisher:Orlando : Psychological Corporation, 1998.

Ask this from your library

Through a battery of tests?

I was thinking if one can adapt Limits of agreement (LoA) estimate to compare the two method agreement. i.e., the interval within which a proportion of the differences between measurements of the two modality lie.

Given the limit of information you provided, and also about different subjects. Alternative is a non parametric approach, [comparing the results for each administrative modality] given that the responses maybe on likert scale, (ie., If you need to compare the 5-point scales one at a time, then non-parametric statistics) and perhabs the average of several Likert scale items which should gives you a scale that "approaches" interval-scale properties. You can use regular parametric statistics, and with three or more groups, ANOVA.

See this discuss, perhabs it might be similar case. https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.researchgate.net/post/What_is_the_most_suitable_statistical_test_for_ordinal_data_eg_Likert_scales&ved=2ahUKEwiJ9PXnztzsAhWhnVwKHTzFAj0QFjALegQIMBAC&usg=AOvVaw0p9DgbQ_8Nx-7nWuh1C5XG

While your data collection completed, now you need to use suitable software (like SPSS) to help you in running your data in order to get the results.

Depending on the version of the TMT you are using (and the associated norms), you are supposed to correct errors as the examinee progresses during the task. For example, if you are using the HRB version of TMT and Heaton's or MOANS norms to correct scores, there is a standardized proceedure for correcting errosr that should be followed; the time that correcting the errors adds to the task contributes to the degree of impairment detected by the measur. The same holds true for Color Trails as well. If you are not correcting the examinee as you go, this confounds their ability to complete the task as they progress. See Reitan and Wolfson (1993) for the proceedures.

Ali Amad

Many thanks for this - but unfortunately this version skips chapter 8 (skips from chapter 6 to 14). I can’t find it anywhere on the internet. Anne

Stephen, thank you for the reply. I didn't correctly express myself and have now corrected the question. I am not interested in one test which would merge all the functions but in all the tests available which cover the mentioned (not all in one test).

I am familiar with the Tower of Hanoi and I saw that the set can be bought online for a reasonable price, but was still hoping that other planning assessment tasks would be available.

Thank you for suggesting the Porteus Maze test, I will look into it.

reply of Ken Andrew Sikaris is absolutely right. Spot Urinary Iodine excretion is utilized for epidemiological study which cannot be translated into individual iodine status.UIE is determined for assessment of IDD in a given population who reside in a defined geographical location.

Your question contains links to the best sources. The tests will come with detailed Manuals. If you don't have a budget to purchase, then try contacting a Pearson Clinical representative; I know they want to facilitate research/publications regarding their products.

Another good source would be the Mental Measurements Yearbook, published by the Buros Institute. Your library may have a subscription; otherwise, you have to pay about $15 US per article. These are commissioned reviews by assessment experts. I know they published one about the Cambridge Prospective Memory Test in 2005, and I think the most recent review of the Rivermead was in 2008.

Careful assessment of AS severity. Consultation at a center with experience in percutaneous approaches to management of aortic stenosis.

Hi Alexandre,

To have valid cutoffs you need a valid dichotomous (or other categorical) outcome variable - which is not likely in areas like this. So, you would need a valid 'satisfied' vs. 'not satisfied' response - ignoring all the variation in between. Because of all the variation in between those extremes, the cutoffs will never be really true, and many people will be included in the wrong outcome group.

That is a huge problem that colleagues and I are currently working on, as we often need cutoffs. So, if possible, always use continuous measures and outcomes for naturally continuous variables.

Good luck!

I used the GT3X to compare the level of activity of nonfrail and frail elderly and many of the frail ones had functional limitations. I understand that the accelerometer might underestimate the level of energy expenditure of the activity, but not the intensity. Even though we found good relationships between the accelerometer variables and the VO2 peak of the participants.

Best Regards, 

Yes, the thresholds are essentially arbitrary - a matter of convention. Basically, kappa and its cousins tell you how much more closely your judges agreed than would have been expected by chance alone. In other words, it's similar to percentage agreement, but controlling for the base rate of the target condition. It's up to you (and the rest of the scientific community) to decide how much better is good enough. As you noticed, there isn't perfect consensus on this score yet.

Please see below for my previous discussion on this: 

Dear Editor,

We read with interest the article by Gibbs and Gibbs on the misuse of the word trend to describe ‘almost’ significant p values [1]. However, we believe this discussion of semantics is clouding a somewhat greater issue in the reporting of statistics in the scientific literature. As Gibbs and Gibbs noted, p values are inferential statistics that give the probability of obtaining a value the same or greater than that found if the null hypothesis was true. However, we argue that p values are outdated and for clinical studies in particular, their use should be avoided. This is not a new concept, however, we hope this letter will serve to remind the readership of the flaws in null hypothesis statistical testing. We will first highlight the problems related with the [mis]use of p values, and then discuss the advantages of estimation-based methods, illustrating this with a theoretical example.

Firstly, the use of p values can often detract from a more important issue when conducting a clinical study, the assessment of clinical significance. The misinterpretation of p values means that readers may mistake ‘statistical significance’ as ‘clinical significance’. As the calculation of p values is heavily dependent on sample size, large studies may demonstrate very small p values that are not clinically significant. In fact, such small p values may in fact be evidence against the use of a particular treatment, as it can make us more confident that a treatment will not have a clinically significant effect (see later example). Secondly, the choice of a significance level of p<0.05 is arbitrary. Such a level may have originated from statistician Ronald Fisher who suggested this as a sensible cut-off, although he never advocated this as an absolute rule [2]. It is absurd to suggest a study that reports a p value of 0.04 is ‘positive’ and another that reports a p value of 0.06 is negative [3]. Such ‘negative’ p values promote fear in researchers and students while also rendering a study less likely to be published [4].

Ever since the end of the 1970’s, the use of confidence intervals (CI) was proposed as an alternative to p values [5]. Confidence intervals present a range of values with which the population mean is likely to lie. More specifically, a 95% confidence interval states that should the experiment be repeated 100 times, the mean of 95 of these experiments would fall within this interval [6]. Such an approach is advocated by the International Committee of Medical Journal Editors who state ‘When possible, quantify findings and present them with appropriate indicators of measurement error or uncertainty (such as confidence intervals). Avoid relying solely on statistical hypothesis testing, such as P values, which fail to convey important information about effect size and precision of estimates’.

Confidence intervals contain a wealth of information as well as including all the information of a traditional p value. If the extreme limit of the confidence interval traverses the null result, then the p value is >0.05 (if 95% CI are used) [7]. Moreover, confidence intervals can be better used to assess the likelihood an intervention has a clinically significant effect. Consider an example, we wish to know the efficacy of two different analgesic agents (x and y) for treating postoperative pain. We undertake two randomised controlled trials (RCT) with both agents and pre-determine a clinically significant reduction in pain as 15mm (on a 100mm VAS) [8]. The first RCT with agent x enrols a large number of participants and demonstrates a mean difference of -5mm (95% CI -3mm to -7mm; p<0.001). The second study with agent y recruits much fewer participants and demonstrates a mean difference of -12mm (95% CI 0.1mm to -24.1mm; p=0.06). Although the p value of the first study is very low, the results indicate that we can be confident this agent does not produce a clinically significant effect and should therefore not be used. The second study, although not statistically significant, does not exclude a clinically significant effect and requires more studies to be conducted in order to increase power and narrow the confidence interval. If we had relied solely on statistical significance, widely different and erroneous conclusions would be made.

We accept that this argument is not new and we applaud the British Journal of Anaesthesia for promoting confidence intervals in their instructions for authors page. However, we feel that this letter should serve as a reminder to the readership both the flaws of p values and the advantages of confidence intervals. We hope this will also encourage authors to report confidence intervals wherever possible.

References

[1] Gibbs NM, Gibbs SV. Misuse of ‘trend’ to describe ‘almost significant’ differences in anaesthesia research. British Journal of Anaesthesia 2015: aev149.

[2] Sterne JA, Smith GD. Sifting the evidence—what's wrong with significance tests? Physical Therapy 2001; 81: 1464-1469.

[3] Rosnow RL, Rosenthal R. Statistical procedures and the justification of knowledge in psychological science. American Psychologist 1989; 44: 1276.

[4] Stern JM, Simes RJ. Publication bias: evidence of delayed publication in a cohort study of clinical research projects. British Medical Journal 1997; 315: 640-645.

[5] Rothman K. A show of confidence. New England Journal of Medicine 1978; 299: 1362-3.

[6] Gardner MJ, Altman DG. Confidence intervals rather than P values: estimation rather than hypothesis testing. British Medical Journal 1986; 292: 746-750.

[7] Cohen J. The earth is round (p < .05). American Psychologist 1994; 49: 997-1003, p. 997.

[8] Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Annals of Emergency Medicine 2001; 38: 633–638.

Dear Dr. Béatrice Marianne Ewalds-Kvist

Thank you very much!

Dear Sharon,

Even though your trajectories are right. It is very difficult to put down any physicians because of their great team work and support for each other no matter how wrong they are. That is why some of them are so smug (not all) even though they could not even insert an IV plug because of the licence that they "earned" by "sheer medical training"

It is never easy fighting over establishments who need their professionals more than their patients. 

Given their huge income and the institutions "lucrative income" are way beyond any elderly "assets" put together - it is difficult to pin down on any negligence because of so many reasons / tools / knowledge the physicians could use too.

I have yet to see the elderly being euthanized personally but I have seen many being abused right under my own nose. And the physicians are left to continue to be abusive openly. But what could I do? Who would listen to me? Who would ever believe me? I am but just a small fry.

That is why euthanasia is a very intricate issue because the physicians have the power to heal and will kill (not all) depending on the situations, advanced medical directories, the family or even the patient's advance request to be euthanized when they are found to be terminally ill or mentally deficit owing to reason(s) beyond their further existence.

Please tread this issue safely, because the repercussions outweigh the benefits of doing such research openly.

Best regards - Mariam

Dear Lizzy,

“The Physical Activity Scale for the Elderly (PASE) assesses the types of activities typically chosen by older adults (walking, recreational activities, exercise, housework, yard work, and caring for others. It uses frequency, duration, and intensity level of activity over the previous week to assign a score, ranging from 0 to 793, with higher scores indicating greater physical activity.”

Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;46(2):153-62. https://www.researchgate.net/publication/14762341_The_Physical_Activity_Scale_for_the_Elderly_PASE_Development_and_evaluation

Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA. The physical activity scale for the elderly (PASE): evidence for validity. J Clin Epidemiol. 1999;52(7):643-51. http://www.jclinepi.com/article/S0895-4356%2899%2900049-9/abstract

Logan SL, Gottlieb BH, Maitland SB, Meegan D, Spriet LL. The Physical Activity Scale for the Elderly (PASE) questionnaire; does it predict physical health? Int J Environ Res Public Health. 2013 Aug 30;10(9):3967-86. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799529/pdf/ijerph-10-03967.pdf 

Best wishes from Germany

Martin

Fingertip-to-floor test and Schober's test are the classic measurements for lumbar spine mobility. They are reproducible and still valid today for the range of lumbar flexion. Rotation and side bending of the lumbar spine are difficult to measure separately from the total spinal rotation and side bending. They are usually measured in toto. 

You should have several (blinded) physicians evaluating the images and/or clinical condition and then compare the results on there decisions.

Dear Oriol,

Nowadays, I do not believe we have data about the "6 sets" separately. There is no reason to build up studies going like this if you are thinking in dementia appropriately diagnosed in clinical pratice only. Besides, the disease's progressing could be quite different among the  subtipes, with early and late onset dementia having very distinct facets. 

But you should try looking for "stages in dementia prevalence", in the link  nia.nih.gov.

Back pain can be due to mechanical causes , which is common or due to inflammatory diseases or malignancy . The investigations are fine . In case , you are worried about calcium level , please check for Parathyroid hormone ( PTH ) level . His back pain seems to have improved & he is asymptomatic at present .

Hi Jose,

Since this is a Basic beginners class and not an advanced class, I would try doing a couple "games" and give them 10-15 seconds.  See how many can get the answer correctly and you will be able to evaluate their understanding prior to give the actual quiz.  Students can sometimes get overwhelmed with looking at too many things at once when first learning and thus lose the focus. This may be a way to get them on the right track. Make it fun - they will retain more!

Good Luck,

Melody

Respected Dr. Sunil,

Your answer clarifies to me very clearly the importance of using accepted abbreviations. This what Dr. Adria Arboix  mentioned to me in his answer on the same question above. I will edit and correct my question immediately so that we will be talking about the same thing. I will put it "IIH" which refers to idiopathic intracranial hypertension.

Currently our muscle biopsies involve a significant incision in the thigh, any advance on this would be welcome. Certainly the procedure as it stands has to be done by a surgeon. Can you describe your minimally invasive method?

The PTSD checklist is a commonly used well normed instrument with a military and civilian version. Rates self report of symptoms over past month.  When used as a change measure this is a concern as therapeutic change may have been over the last couple weeks before administration. To my knowledge this "over the last month" issue has not be addressed. 

Interesting question with no interesting answer. There are some some indications that host mannose-binding lectin gene polymorphism is related to susceptibility to chlamydia induced inflammation. Though I am not sure that it is not related to susceptibility to coinfection.

It is an gain asymetry pattern also knwn as isolated directional preponderance.

I've seen it sometimes in Meniere's Disease patients, but without such fluctuation you comment.

It's also described in migraine patients:

Does the patient has any migraine or migraine-equivalent symptom, ?

The regulations for investigational drugs and investigational devices are not the same, though both are regulated by the Food and Drug Administration (FDA).  The regulations, guidances, and FDA warning letters can be found on line at http://www.fda.gov/.

Palpitations, Arrhythmias, and Awareness of Cardiac Activity

Arthur J. Barsky, MD, Annales of Internal Medicine, 1 May 2001, Vol 134, No. 9_Part_2>

Abstract: Somatic and visceral symptoms have a surprisingly weak relationship to objective measures of tissue pathology. This is exemplified by the poor correlation found between palpitations and cardiac arrhythmias. Many factors other than extent of disease influence symptomatic distress, and since symptoms are such a crucial feature of illness and of medical practice, much more investigation of these nonbiomedical influences is needed. Although experimental laboratory paradigms facilitate such investigation, there are problems involved in generalizing from laboratory findings to the reporting of the symptoms of disease in daily life. In studying the awareness of cardiac arrhythmias and of resting heartbeat, we have found that the palpitations of patients who somatize more and have more health-related anxiety and more psychiatric distress are significantly less likely to be related to demonstrable cardiac arrhythmias than are the palpitations of other patients. The accurate awareness of arrhythmias, however, is not associated with the accurate awareness of resting heartbeat. Even more surprising, a relatively large proportion of heart transplant recipients are accurately aware of their resting heartbeat. This work poses more questions than it answers. In so doing, it underscores some of the technical difficulties of conducting research in this area and shows how little is known about symptom perception, processing, and reporting.

Many papers related to hypersensitivity to somatic stimuli refer to IBS:

Pain Med. Nov 2010; 11(11): 1619–1627.

Ischemic Hypersensitivity in Irritable Bowel Syndrome Patients

QiQi Zhou, PhD,Roger B. Fillingim, PhD,Joseph L. Riley, III, PhD,and G. Nicholas Verne, MD

Thermal hypersensitivity in a subset of irritable bowel syndrome patients. Zhou Q, Fillingim RB, Riley JL 3rd, Verne GN. World J Gastroenterol. 2009

Affective disturbances modulate the neural processing of visceral pain stimuli in irritable bowel syndrome: an fMRI study. Elsenbruch S, Rosenberger C, Enck P, Forsting M, Schedlowski M, Gizewski ER. Gut. 2010 Apr;59(4):489-95.

As regards hypervigilans in general it refers to trauma.

Finally a short note: Another approach would be to search for data on the estimated number of unreported cases for specific diseases and to examine the evidence for the estimation of the number of unreported cases.

In German we use also the term "Dunkelziffer" (engl. dark figure) in public health care. In the figurative sense "Dunkelziffer" refers to a disproportion of diagnosed (or even statistically recorded or reported) disease cases to actual disease frequency.

Perhaps these papers help you:

Kettunen, J. (2010). Cross-evaluation of degree programmes in higher education, Quality Assurance in Education, 18(1), 34-46.

Kettunen, J. (2012). External and internal quality assurance in higher education, The TQM Journal, 24(6), 518-528.

consider pyoderma gangrenosum , and treatment is steroids

There are a few good self-report measures designed to get at DSM personality disorders. The Millon Multiaxial Clinical Inventory (MCMI-III) is very good; the Personality Assessment Inventory (PAI) is also said to be quite good, though I haven't used it. Each would include a Paranoid Personality scale. There is a Paranoia subscale on the SCL-90-R that has good items, though it doesn't ask specifically about DSM criteria.

One problem with inventories that ask explicitly about DSM criteria is that they are both transparent and obviously pathological. This is especially problematic with paranoid people! Lesley Morey developed personality disorder scales for the MMPI-2 about 25 years ago. This scale wouldn't have the criteria, but was designed to differentiate paranoids from "normals."

These are all commercially available measures.

There also are measures of "subclinical" paranoid ideation. These could be useful for you. They may be transparent, but won't be as obviously pathological or undesirable.

I don't know much about it, but Fenigstein and Vanable published one in the Journal of Personality and Social Psychology in 1992 that has been used in a number of studies. I'll attach a copy of the article.

Sorry if I insert here such my suggestion.

I am not here to outline you the importance of the HRV current studies and I have not to remember you that the current linear or non linear methodologies are not completely satisfactory. Of course every day we find papers published also in valuable international journals that continue to use standard linear indexes and FFT or DFT for their clinical investigations and conclusions. Non linear methodologies have their valuable content also if currently they still do not find a continuous clinical appreciation. Usually three bands are considered in the frequency domain , as you well know, the VLF, the LF , and the HF for short 5-6 minutes recording. We need to remain in this framework, we need to use such bands for our estimations but my modest opinion is that the basic methodology as well as the physiological setting need to be advanced. This is the reason because we have studied for several years a new method, called the CZF method. We have verified, however, that such method, although of great interest, results of difficult interpretation for some clinicians. Consequently we have elaborated a new method, the new CZF version , that , in addition to the rigour of the previous formulation , gives results that give immediate clinical interpretation.

The method as well the software for your experimentation are given in our site www.saistmp.com Consequently I invite all you to visit the site and go to use such new method in your experimental as well as clinical conditions and verify directly its interest. The present software is the primary elaboration. Within a brief time we will give the complete version responding to all the formulation of the method. All the researchers that , at this time, will result using currently such new CZF method will receive obviously automatically the updates.

A final question. We have experienced the method on a large number of subjects and in some different pathological conditions. Consequently don’t hesitate to contact me if you need help, suggestions, questions, previous results that may help you in your use of the method (stmp@saistmp.com)

Have a look on www.psychiatry.org/dsm5 for a first and second screening along the lines of DSM-5: questionnaires can be freely downloaded.

The classical measures are LSAS (Liebowitz), SPS (Social Phobia Scale) and SIAS (Social Interaction Anxiety Scale), of which the LSAS is the most frequently used for treatment outcome.

Since you specify those two personality disorders, I'm guessing that you want to test certain psychodynamic formulations (see, for example, Storr's book Neurotic Styles, or Mardi Horowitz's work on short-term dynamic psychotherapy of stress response syndromes). Lazare et al. (1966) developed a simple checklist measuring these two personality styles (along with an "oral" style). A version of this known as the Basic Character Inventory (Svenn Torgersen, 1980?) has been used in a number of studies over the years. I don't have a copy, but one of the researchers who has used it might be able to help.

Sid Blatt's Depressive Experiences Questionnaire (DEQ) gets at a similar distinction (here termed "anaclitic" vs. "introjective" depression), as does Beck's distinction between "sociotropy" and "autonomy" (the Personal Styles Questionnaire, I think?). The Inventory of Interpersonal Problems (IIP) is another promising direction. Some of the literature on the DEQ, IIP, and Personal Styles Questionnaire was reviewed by Mattias Desmet in a 2007 dissertation: http://www.psychoanalysis.ugent.be/pages/nl/artikels/artikels%20Mattias%20Desmet/Doctoraat%20Mattias%20Desmet.pdf

I agree with an earlier commentator that the MCMI-III might work, though it is very strongly linked to the DSM criteria. So might the Anxiety and Repression scales of the MMPI-2, though they are totally unlinked with the DSM. (I'm not sure how closely you want to adhere to the DSM here, as opposed to underlying psychodynamics.)

I recommend the Borderline Personality Inventory developed by Leichsenring (1999). I use the Polish adaptation of it and it works really well. Maybe you should contact with the author?

Leichsenring, F. (1999). Development and first results of the Borderline Personality Inventory: a self – report instrument for assessing Borderline Personality Organization. Journal of Personality Assessment, 73, 1, 45-63.

Dear Yasuko,

Thank you for the additional information. There are many differing tests that can measure essentially the same thing, but from different perspectives. Often a psychologist will use a full battery assessment instrument such as the Wechsler Scales and, if some portions of the test do not produce expected results, other tests are administered to reassess those areas in a slightly different format. This is used sort of like ‘double checking’ the results. Language, of course, plays a prominent role in testing. Responses will be inaccurate if the Subject does not fully understand the question, etc. The types of tests you mentioned previously may be a ‘double check’ of the prior results for verification, or they may have been administered to better understand the Subject’s ability to ‘process’ auditory and visual information.

You did not mention ‘academic’ tests. Tests that measure academic skills are usually administered along with the tests you discussed. The academic scores are then compared to the cognitive scores in order to determine if the subject is achieving to the level of their potential. The processing tests are administered to determine if a deficiency exists that may be inhibiting the Subject from learning up to his or her level of measured ability.

The Baum test you mentioned is usually part of a full battery assessment as well. It is a ‘projective’ test that can give a general view of the Subject’s emotional state, degree of concern, attention to detail, general attitude, etc., and allows comparison of motor skills with other scales.

Certainly the psychologist you are concerned with appears to have been attempting to conduct a thorough assessment. However, such assessments can be very time intensive and tiring (This can also be part of the overall assessment observation). You did not mention why the assessment was being conducted. Usually such evaluations are conducted in order to answer a ‘question’. The question arises from some sort of perceived difficulty that the subject is displaying. Usually, the battery of psychological tests is selected in an attempt to answer the problem addressed in the research question.

Again, I hope this explanation may be beneficial to you.

Scub

We have Anthropometric measurements, clinical examination for signs and symptoms, Biochemical analysis for any biochemical indicators, and Diet history or dietary assessments to help you find out the deficient nutrients from ones diet.

Under Anthropometric assessment, we need to find parameters like, Weight, height, Age, Waist hip ratio, %body fatness, Skin fold thickness and many more. This helps us find the current nutrition situation and status of this client.

Clinical assessments: this will provide detection of nutritional deficiencies by examining the different body organs like eyes, nails, fingers, tongue, muscles bone stomach and so on..

Biochemical assessments help us find specific biochemical makers relating to specific nutrient deficiencies or toxicities. For example serum, albumin, urine.

Dietary assessments: From the previous diet records of the patient, we can tell the missing or excess nutrients in the diet, these methods include, FFQs, 24 hr recall, food records etc.

From these, just pick the most relevant to your study according to your target population and which condition you are investigating. But you can't miss to have some few anthropometric measurements in you study if your dealing with nutrition status.

Goodluck!

It depends on what you mean by "judging" and your motive for doing it. I guess most of us do.In a way you have to to some extent.Getting a feel of where these parents are coming from may help you in management. Judging needs to be empathetic and sympathetic and also positive and not negative.You look for unspoken evidence from their body language from what they don't say. This is what I call the art of paediatrics. It helps you get the answer behind the answer,especially as more often than not our patients cannot speak for rhemselves

Through the study of the behavior of each one individually and note commonalities between them to focus and try to improve the clinical role.

The role of culture is central in infuencing PTSD symptoms. For example, cultures indoctrinate us to view the world in certain ways and to use our emotions and bodies in different ways. Many cultures are personalistic in the sense that their world views believe in autonomous spirit beings which can affect human beings for good or bad. Where I did my fieldwork in India many years ago many psychiatric conditions were often viewed as ‘spirit possession’, since this is psychologically accessible to people who believe in a cosmology which has various kinds of spirit beings. Cultural symbols are powerful in informing emotions which affects psychoneuroimmunological systems. Ancestral shamans used technologies of the mind in order to treat all kinds of traumatic circumstances. While the phenotypic symptoms of PTSD are similar, understanding of its cause and prognosis is different. In Latin America PTSD may be understood as ‘nervios’ and ‘susto’, while in Iranian/Afghan, North Indian cultures it is often referred to as ‘asabi’ or ‘hona bud’ . What is important is that the person who has PTSD symptoms needs to retrieve some kind of ontological security. Cultures may significantly help via the performance of rituals which neurologically create endocannabinoids while decreasing stress hormones noradrenaline, adrenaline and cortisol. Rituals are powerful in that they manipulate powerful emotions which inform somatic feedback systems. Many healing rituals performed by ritual specialists, shamans, religious specialists in collective societies use healing rituals as social events which act to unite social members and reaffirms socio-religious worldviews. Social rituals are very powerful in manipulating emotions which can act to heal or transform people with psycho-physical maladies. The social mind is powerful in its ability to imagine all kinds of things which directly affects psychoneuroimmunological response.