Paresthesia Case Study: Diagnosis and Management

Paresthesia Case Study: Diagnosis and Management ABSTRACT Parasthesia is defined as a sensory disturbance with clinical manifestations such as burning, prickling, tingling, numbness, itching or any deviation from normal sensation1. Paresthesia of the inferior alveolar nerve can occur during various dental Procedures like local anesthetic injections, third molar surgery, orthognathic surgery, Ablative surgery, Implants, and endodontics. This case report highlights a commonly occurring and often reported problem of Paresthesia involving the Mental Nerve during endodontic treatment. Most of the previous case reports have used radiographs for the diagnosis and management of these cases. Since the radiographic image is a 2 dimensional image it has its limitation while a 3 dimensional imaging modality like a cone beam computed tomography (CBCT) provides the clinician with additional information which can be critical in the management of cases. The exact 3 dimensional location of the mental foramen in relation to the apex of the concerned tooth ca n be confirmed using CBCT scans, helping make more informed diagnosis and treatment plans. This case was successfully managed using CBCT images for guidance during the root canal treatment. INTRODUCTION Parasthesia is defined as a sensory disturbance with clinical manifestations such as burning, prickling, tingling, numbness, itching or any deviation from normal sensation1. Paresthesia of the Inferior Alveolar Nerve and its branches can occur during various dental Procedures like Local Anesthetic Injections, Third Molar Surgery, Orthognathic Surgery, Ablative Surgery, Implants, and Endodontics2, 3. Damage to vital structures in the head and neck area during dental treatment is always a vexing prospect for the clinician. During Endodontic Treatment precautions have to be taken against this, as there is a possibility of injury to a vital structure with the instruments or chemicals being used and also a chance of depositing infected material with their byproducts from the tooth into these areas causing a subsequent immunological response from the body. Today we are able to use 3 Dimensional imaging to locate and respond to such situations much more precisely than ever before4,5.This case highlights a commonly occurring and often reported problem of Paresthesia involving the Mental Nerve during endodontic treatment6.7 which was managed using a CBCT to offer the patient a predictable treatment. Most of the previous case reports have used OPG’S and Intra oral periapical radiographs for the diagnosis and management of these cases. Since these are 2 dimensional imaging technique s they have their limitations. Cone Beam Computed Tomography (CBCT) is 3 dimensional imaging modality which provides the clinician with additional information which can prove to be critical in the management of such cases. CASE REPORT A 32 Year old female patient was referred to the Department of Conservative Dentistry with the chief complaint of a dislodged temporary restoration in a tooth undergoing endodontic treatment at a private dental clinic. Patient gave a history of Root canal treatment having been started 2 weeks back. Clinical Examination revealed an exposed access opening and extreme tenderness to percussion. Radiographic evaluation confirmed the history presented by the patient (Fig 1). A differential diagnosis of Periapical granuloma/ Periapical Abscess was recorded and the patient was advised to complete the Root canal treatment. In the first appointment the access opening was refined under local anaesthesia and the pulp tissue remnants were extirpated using a barbed broach followed by temporistion.The patient was recalled after 4 days for Root canal instrumentation. In the second appointment local anaesthesia was administered and working length determination was done using an apex locator (Propex 2,Dentsply) followed by confirmation with a radiograph (Fig 1). The working length was kept at 0.5mm short of the radiographic length of the tooth and the root canal instrumentation was carried out. Saline and Sodium Hypochlorite were used to copiously irrigate the root canal space and instrumentation was carried out with the Protaper Rotary system. The root canal was dried and the tooth was temporized for obturation in the following visit. On the next visit 7 days later the patient complained of Parasthesia of the lower lip from the date of the previous visit. On examination there was Parasthesia of the left half o f the lower lip and its distribution was consistent with the supply of the mental nerve (Fig 2). A close examination of the IOPA revealed the presence of the mental foramen directly below the apex of the treated premolar indicating possible deleterious effects of the previous procedure causing and periapical inflammation and subsequent damage to the mental nerve. A CBCT was taken to confirm the exact location of the mental foramen. The CBCT images confirmed the extreme close nature of the mental foramen to the apex of the treated premolar (Fig 3, 4). The distance between the apex of the premolar to the mental foramen was measured to be 0.4mm by using the CBCT software. Taking this into account the working length was reset at 1.5 mm short of the radiographic apex. The tooth was then instrumented to the new working length and the canals were irrigated with saline and sodium hypochlorite followed by drying using paper points. The patient was advised that the Parasthesia will gradually disappear and that the lip will regain normal sensation and was scheduled weekly recall appointments. The Parasthesia was still present at the one week recall appointment until the 6th week after which gradual normalization was observed. At end of two months the Parasthesia had completely disappeared and normal sensation had returned. Endodontic treatment was resumed keeping the new working length. The instrumentation was completed and the tooth was obturated using F3 (Protaper Dentsply) size gutta percha for apical fill and Obtura 2 with System B for back fill using continuous wave of condensation techniqueA one week follow up was done to confirm the absence of any recurrence of the Parasthesia following the obturation. Finally the tooth was restored with a No.1 size fiber post (Angelus Brazil) and crown was placed (Fig 5). DISCUSSION Dental radiographic evaluation is a fundamental tool for endodontic diagnosis. Conventional Intraoral Periapical radiographs are routinely employed during endodontic diagnosis to examine the tooth, identify the pathology and plan the treatment. However, a conventional radiograph is a two dimensional image of a three dimensional object and consequently has limitations. Numerous prior studies have demonstrated the effective use of CBCT in the assessment of complex endodontic cases .In cases where location of a vital structure such as the mental foramen or the Mandibular canal are concerned the 3 Dimensional imaging capabilities of a CBCT are invaluable. With CBCT and its advanced 3 D reconstruction software, it is possible precisely orient the teeth under treatment with the adjacent anatomic structures across a multitude of planes to get measurable values of distance, which help with the consequent predictable treatment plan. In situations of close proximity of a nerve to a tooth which is being endodontically treated various possibilities of damage to the nerve exist. Mechanical compression of the nerve, Damage to the nerve due to over instrumentation, Extrusion of necrotic debris and toxic metabolites from the root canal space, overfill or the passage of various endodontic materials (root canal irrigants, sealers, and paraformaldehyde containing pastes) into the vicinity of the nerve or its branches. In the present case the most probable cause of the Parasthesia could have been an acute exacerbation of the Periapical infection due to Extrusion of the necrotic debris from the root canal space into the mental foramen space and/or inadvertent direct mechanical compression of the nerve because of over instrumentation of the tooth during working length determination Direct peripheral nerve injury has been previously classified into three basic types: Neurapraxia, Axonotmesis and Neurotmesis 8. Neurapraxia occurs due to a slight compression of the nerve trunk resulting in a temporary conduction block. Neurapraxia of the inferior alveolar nerve or mental nerve will usually manifest as a Paresthesia or Dysaesthesia of the lip and chin region 9. Axonotmesis refers to the actual degeneration of the afferent fibers as a result of internal/external irritation resulting in anesthesia 10. Neurotmesis is the complete severing of the nerve trunk, resulting in permanent Paresthesia which can only be corrected by microsurgery and has a more guarded prognosis (8-10). The most likely form of injury in the present case seems to be Neurapraxia due to either periapical infection or direct injury by over-instrumentation/inadvertent passage of the root canal irrigant or both. The tooth responded well to conservative treatment, and upon completion of the debridement and disinfection of the root canal, the symptoms of periapical infection subsided and Paresthesia started to diminish. CONCLUSIONS The lower mandibular premolars very frequently are in close approximation to the Mental foramen and the Mandibular canal. The pre-operative radiograph does provide us with a 2 dimensional image but better more accurate location can be obtained using the CBCT whenever possible. Finally the best method to prevent any damage to the Mental Nerve is to locate it.

My Philosophy of Education Essay -- Philosophy on Education Statement

Philosophy of Education "I just know I'm next. Don't call on me, don't call on me. Please, please! Whew! ! ! That was a close one. I hate it when that teacher calls on me to answer questions in front of the whole class. I never know the answers. He knows I don't know the answers and that's why he always calls on me. Yep, he hates me alright. One of these days I'm going to...Oh, yes Mr. Jones, I can come work that problem for you. Thank you, sir." What you have just read are thoughts that took place in the minds of any number of students, sitting in any number of classrooms, today. In the eye of the student, the teacher is out to ultimately destroy him while all of his classmates stand idly by and watch. In reality, of course, this is not the case. A teacher's job can be very thankless and unappreciated at times, not only by the student, but by parents and the general public also. In the long-run, however, the life changing effects a teacher can have on a child's life is priceless. Through the course of this paper, my personal views on the nature of students, the nature of knowledge, the overall purpose of education, teaching methods I intend to use, and the curriculum I intend to concentrate most on in teaching elementary aged children will all be brought to view. In addition to these areas, I will discuss why I disagree with Rousseau in his belief that a child's education should be centered around only the things that he/she wants to learn. I will also discuss why I agree with him in his belief that children should not be taught through memorization. In addressing the nature of students, I would have to agree with the Sophists in the belief that, although all children are not born on the same intellectual level, ... ...at he has read. Without sufficient reading and comprehension skills, the child will now not only be an inadequate reader, but an inadequate writer as well. There are an infinite number of additional examples of skills that grow out of the ability to read at an age appropriate level. In conclusion, I believe that a child is able to accomplish anything if he continues to try. It is also my beliefs that: 1)students are directly influenced by parent/teacher collaboration (or the lack of it), 2) education is an effective way of building productive, self-sufficient citizens, 3) methods of teaching and discipline should both be directly tied to the teacher's code of ethics, and 4) reading is the most important subject for the child to learn in elementary school. Regardless of the manner by which a teacher does it, the effects he/she has on a students life is immense. My Philosophy of Education Essay -- Philosophy on Education Statement Philosophy of Education "I just know I'm next. Don't call on me, don't call on me. Please, please! Whew! ! ! That was a close one. I hate it when that teacher calls on me to answer questions in front of the whole class. I never know the answers. He knows I don't know the answers and that's why he always calls on me. Yep, he hates me alright. One of these days I'm going to...Oh, yes Mr. Jones, I can come work that problem for you. Thank you, sir." What you have just read are thoughts that took place in the minds of any number of students, sitting in any number of classrooms, today. In the eye of the student, the teacher is out to ultimately destroy him while all of his classmates stand idly by and watch. In reality, of course, this is not the case. A teacher's job can be very thankless and unappreciated at times, not only by the student, but by parents and the general public also. In the long-run, however, the life changing effects a teacher can have on a child's life is priceless. Through the course of this paper, my personal views on the nature of students, the nature of knowledge, the overall purpose of education, teaching methods I intend to use, and the curriculum I intend to concentrate most on in teaching elementary aged children will all be brought to view. In addition to these areas, I will discuss why I disagree with Rousseau in his belief that a child's education should be centered around only the things that he/she wants to learn. I will also discuss why I agree with him in his belief that children should not be taught through memorization. In addressing the nature of students, I would have to agree with the Sophists in the belief that, although all children are not born on the same intellectual level, ... ...at he has read. Without sufficient reading and comprehension skills, the child will now not only be an inadequate reader, but an inadequate writer as well. There are an infinite number of additional examples of skills that grow out of the ability to read at an age appropriate level. In conclusion, I believe that a child is able to accomplish anything if he continues to try. It is also my beliefs that: 1)students are directly influenced by parent/teacher collaboration (or the lack of it), 2) education is an effective way of building productive, self-sufficient citizens, 3) methods of teaching and discipline should both be directly tied to the teacher's code of ethics, and 4) reading is the most important subject for the child to learn in elementary school. Regardless of the manner by which a teacher does it, the effects he/she has on a students life is immense.

Java :: essays papers

Java Java is the substance whose aroma is awakening the Internet community. It is a new programming language developed by Sun Microsystems that has much in common with the beverage that shares its name. It's good, it's hot, and people know it around the world. Java (the programming language) beats the other stuff hands down though, it's free. Many have heard of Java, yet few know what it is, or what it can do. It certainly has the potential to become a part of our everyday lives, existing in our mobile phones, televisions, and Internet browsers. If you are interested in your future read on. Java is still in its infancy stage, yet to fulfil its intended purpose. Designed in 1990 as an embedded language for consumer electronics, it was later discovered to be an ideal interface to the Internet. In 1996, Netscape added Java support to its popular Navigator Web browser. The Web began to stir from its static text coma as excited programmers began to incorporate Java applications, "applets", into their Web pages. An applet is like an application, but it doesn't run stand-alone. An applet must adhere to a set of conventions that allows it to run within a Java-compatible browser. The technology is still evolving, and today, most Java applets are simple animations, or user interactions. The future is brighter, promising full-blown applications over the Internet; imagine using Microsoft Office from your television. For now, though, those who have experienced an applet may be left disappointed. A casual user is unlikely to be impressed with scrolling text, or simple animations, especially if they must pay for them with increased download times. Behind the scenes, unbeknownst to them, truly amazing things are happening. A Java applet begins its life by being "called" by a Web page. To be technologically correct, the applet is embedded in the Web page. The Web browser then downloads the applet and runs it on your machine. If you just missed the amazing part: it runs on your machine. How can a program from an unknown source be trusted to run on your computer without your permission? It can't unless that program was created using a secure language like Java, and then wrapped with a secure viewing browser like Netscape Navigator. The concept of being able to run applications on your system is significant for several reasons. If you want to see a picture, but don't have a picture viewer, you can get both at once.

Examine the influence of Heaneys childhood upon his poetry :: English Literature

Examine the influence of Heaneys childhood upon his poetry Introduction Seamus Heaney was born on a farm in county Derry in North Ireland on April 13th 1939 he was one of nine children. The Heaney family had lived in that area for centuries and had been farmers for generations. He grew up in the country and the countryside was a crucial focus point for his poetry, this is shown in the poems The early purges, The forge, Digging, Follower and Death of a naturalist. He grew up in a rural community which was very important to him as well as village traditions, history and religion. Nature was important to him. This is illustrated in Death of a naturalist and Follower. He looked back to the farm for inspiration in his writing when he writes about the farm in Digging and the follower. In Follower, Seamus writes about his father Patrick. Seamus had a great deal of respect and admires his father for his farming skill again this is evident in Follower. Seamus and his father separated as Seamus grew smarter and away from the farming life and towards poetry and literature. Heaney was Catholic and at school he became aware of the Catholic and Protestant problems in Ireland which later inspired him to write about politics and the problems in Ireland. Heaney wrote very realistic poems about life in the countryside and wanted to show what it was really like (rough and hard).This is clear in Death of a Naturalist and Early purges. When he was twelve he won a scholarship to St Colun's boarding school in Derring later he won another scholarship to Queens university where he studied English. When he was at university he started to write poems and the increasing problems in Ireland became apparent to him and his poems examined these problems. In the early sixties he wrote his first volume Death of a naturalist. Analyzing four Heaney Poems I have chosen Death of a naturalist, Follower, Digging and The early purges because I think they represent the influences that Heaneys childhood had on his poems. Death of a naturalist was one of Heaneys' first poems and was the title of his first volume. The poem symbolizes the innocence of childhood because he uses simple and uncomplicated language. The teacher in the poem is very patronizing and explains sex and mating in a very toned down way she said, 'The daddy frog was called the bullfrog and how he croaked and how the mammy frog laid hundreds of little eggs and this was frogspawn'. The early part of the poem is seen through the eyes of a child and as

Role of Technology in Sales Management

Technology is an absolute need we cannot escape from. Let’s just say, it has a very big role in most aspects of our lives. In other words, it answers most of Mankind problems. Across centuries technology evolves. The importance of technology is aiming for comfort of use in whichever form it is. It always directs for easiness in life. Take the mobile technology for example. The faster the world is moving, the more hi-end the features are offered. Laptop gets thinner and smaller. It becomes more compact every year and offers more capabilities and top performance. One of the biggest challenges currently facing sales management is how to effectively and affordably train a large and/or geographically dispersed sales force. †¢24-hour access. Through the Internet which is available 24/7. Management can make sales of new product, services or product updates. Customers can access the web from their offices, homes or remote Internet locations at their convenience, at a time that best fits their schedules and maximizes comfort, reduces stress, and most importantly, allows them to purchase something even after business hours. Easy management of geographically dispersed teams. Managing a geographically dispersed team is always a problem, with training being one of the more significant struggles. By employing modern day technologies, however, sales management can increase sales performance while balancing the time required for productivity. Through database reporting system, they can view the progress of a sales team anywhere in the world. †¢In stant new product information and current product updates. Once of the biggest headaches for companies is the lag time between finalizing a new product or service and getting their sales force up-to-speed and actively selling it. With modern technology in Sales, it is like a big aspirin tablet for this headache, and can eliminate it. When the new product or service is finalized, management can create a features/benefits using technology for their salespeople to complete. Depending on the complexity of the offering, salespeople could competently sell the product the next day. Instant results measurement. Sales persons can receive instant assessment of their performance at any given time. They can review assigned areas and given tasks. This will help ensure understanding and retention of the information, making them more productive salespeople. For management, this instant feedback feature provides a method of tracking individual progress and a benchmark for individual and team success. †¢Economical, low relative cost. Sales team can train online which produces a strong economic savings, too. Oftentimes, airfare, hotel stays and per diem costs equal, if not surpass, the investment in actual training. With online training, these costs are eliminated. And if you are large corporation, the cost involved in simply producing printed material and sending it to the sales force can be tremendous. What's more, salespeople can remain productive in the field, serving their customers without being pulled away for training.

Like Water for Chocolate Essay

Suggests that the soup has made her feel like a baby again given that while she is still in her mom’s belly she cries very hard when onions are chopped and it suggest the impact of food to Tita. After drinking the soup Tita has miraculously recovered from the loss of pigeons which she kept as pet and that triggered her sense of loosing Pedro and R erself to cook she fell in love with it and got a part time job as an assistant to a cooking teacher. Even though she has a lack of precision she was hired because she wasn’t afraid to fail and has a passion to cook unlike the others and getting hired made her feel confident, hence gaining control of life through cooking. The protagonist, Tita in Like Water for Chocolate gains control through cooking as well. Cooking is the only thing Tita love to do because Mama Elena bans her from doing a lot of things; the kitchen is the area where she can retreat from Mama Elena’s demands. When she cooked quail in rose petal sauce she controlled and triggered a lot of people’s emotion. Her sister Gertrudis was the first on affected by the dish, it aroused her sexual desire. She fled naked from her burning shower and when on a horse, galloping away with a soldier. Another incident where she gained control is the Chabela wedding cake she made for her lover Pedro and Rosaura. Even though she couldn’t stop the wedding, she made everyone cry. She made people cry for her tragic experience not only the guests cried, Mama Elena cried as well. She lost control of her life but through cooking she gain control of people’s emotions. In Like Water for Chocolate, food is not just a nutrition it acts as a very important nurturing role. The ox-tail soup Dr. John gave Tita has recalled the best moments of her life and brought back memories of her and Nacha making ox-tail soup together, chopping onions. It suggests that the soup has made her feel like a baby again given that while she is still in her mom’s belly she cries very hard when onions are chopped and it suggest the impact of food to Tita.

Post Traumatic Stress Disorder in Children Essay

Abstract Post Traumatic Stress Disorder affects not only adults but also children. There are four major ways by which traumatic events may affect the psychological state of children: cognitively, affectively, behaviorally and psychosomatically. There are questions as to the sufficiency of the instrumentation used in determining and measuring of the disorder. Studies also show that the fear experienced by adults in seeing signs of aggression in children may be affecting adversely affecting the possible therapeutic benefits of normal child’s play and physical activity. There may be a need for programs specifically geared toward educating parents and primary care givers of children suffering from PTSD in how to handle and deal with the child’s disorder and psychological needs. Post Traumatic Stress Disorder in Children as a Result of Violence, Crime and War It is not unusual for most adults, particularly those who are parents, to keep bad things away from children. As much as possible, childhood should remain a time of innocence and joy without the responsibility or care for matters that trouble the world. But what if it just cannot be avoided and bad things happen to children? In the aftermath of unhappy events, how do children display trauma and what are the things that people should know in dealing with children suffering from post-traumatic stress disorder?   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   For example, the September 11, 2001 terror attacks left behind families and children who have lost moms and dads in that instant. Even adults and children who were indirectly affected by the attacks have grown to suffer feelings of anxiety and shattered security in their personal and familial safety (Smith & Reynolds, 2002). Besides the inevitable feelings of grief, children especially were left behind and often contend with nightmares and morbid pictures of the traumatic deaths their loved ones experienced as well as the stress and difficulty of trying to picture lives without mom or dad. It is also important to remember that the effects of trauma are not limited to those who suffer it directly (Sims, Hayden, Palmer & Hutchins, 2000, p. 41) The ubiquity of television also afforded children at home not only news of the attacks but also vivid pictures and descriptions of the tragedy and all its violence. The case of a 7-year old boy named Johnny is cited in the study (2002) by Smith and Reynolds.: Following the 9/11 attacks, Johnny developed a constant fear of his parents leaving home and getting killed by â€Å"bad men.† He also developed a phobia of elevators and would throw tantrums whenever his parents tried to make him use one. Johnny admitted to his therapist that his fear of elevator stemmed from a story he heard of how â€Å"people in the Twin Towers were trapped and killed while riding in the elevators.† (Smith & Reynolds, 2002)   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Neither Johnny nor his family were directly involved or affected in the terror attack. The mental and emotional strain suffered by survivors and those affected by this very high profile event led to the American Psychiatric Association’s setting up of counseling services â€Å"focusing on grief, acute stress and Post Traumatic Stress Disorder (PTSD) (Smith & Reynolds, 2002). What is PTSD? Originally associated with survivors and veterans of the Vietnam War, PTSD refers to an impairment of an individual’s capability to function in everyday following exposure or experience of an exceptionally disturbing event. Besides war, this has grown to cover the ill mental and emotional effects of â€Å"natural and civilian catastrophes, criminal assault, rape, terrorist attacks and accidents.† (Murray, 1992, p. 315) The DSM IV presents a more broadened definition of traumatic exposure as â€Å"the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,† and which evoked â€Å"intense fear, helplessness, or horror† (Mcnally, 2003). This broadened definition also qualifies extreme horror at what other people’s experience or events outside their environment as possible causes of PTSD. Symptoms of PTSD include vivid and morbid imagery, numbing, disruptions in thoughts and cognition, delayed response and reaction, strong feelings of anxiety, persistence of nightmares and difficulties in dealing with and solving problems. (Foa & Meadows, 1997) Saylor and Swenson, et.al state that before the late 80’s there was minimal attention given to how children were affected by traumatic events. It took two powerful hurricanes, one devastating earthquake and the bombing of the Oklahoma Center before it was realized that there were very little preparedness in ministering to the psychological needs of traumatized children   (Saylor, Swenson, Reynolds & Taylor, 1999, p. 70). In 1999, psychologist Barbara Lowenthal pegged the number of children in America being exposed to traumatic events each year at four million. These traumatic events include â€Å"physical, sexual and emotional abuse; neglect; accidents; severe injuries; and natural disasters.† Lowenthal also says that these children are at a high risk of suffering from PTSD and may cause them to be prone to developing phobias and other neuro-psychiatric disorders including anxiety and depression (Lowenthal, 1999). The National Center for Posttraumatic Stress Disorder (NCPTSD, 2001) reports that there is a higher likelihood of psychological symptoms associated with PTSD to be found among children who have experienced traumatic events before the age of 11 compared to those who suffer trauma at later ages. (Alat, 2002) Lowenthal also says that besides the general symptoms of PTSD, children who have suffered trauma are likely to develop difficulties in forming relationships, cognition and learning, as well as a â€Å"numbing† that may make affected children experience difficulty in understanding and expressing their feelings in addition to regulating their emotions. This often leads to â€Å"provocative behaviors† and avoidance of intimacy. (Lowenthal, 1999). In his article in the Journal of Multi-cultural Counseling and Development in 2004, Clinical psychologist and Fellow of the American Psychological Association (APA) Gargi Roysircar studied the case of 20-year old Yugoslavian à ©migrà © Stephen, who at the age of 10 witnessed the height of the civil war between Christians and Muslims in Kosovo in 1990. Stephen remembers witnessing about 80% of his classmates get killed by bombs, sniper shots and gunfire as they walked to and from school. At age 14, Stephen was taken by his father to the frontlines and be trained in combat to fight with the Serbian army. The next two years wold take Stephen all over the Balkans and would expose him to all kinds of privation and war atrocities. Eventually migrating as political refugees in the United States, in 1999, Stephen demonstrated difficulty in acculturation and adjustment. The constant displacement he experienced in war along with the mistrust bred by his past and cultural paranoia fostered by the Croatian community they lived with made it difficult for Stephen to acclimatize to peacetime setting.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Roysircar describes Stephen as having â€Å"recurrent thoughts and images of his violent experience in the Balkans. He experienced nightmares, hostility and a profound sense of a lack of belonging. Stephen also often recounted the difficulties he experienced including â€Å"hiding in a basement and eating rats† especially when angry. He also displays a deep-seated hatred for the Muslims and believes â€Å"the Middle East should be wiped off the face of the Earth† (Roysircar, 2004).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This kind of behavior can very well be treated as expected according to an study published in the Australian Journal of Early Childhood in 2000. The researchers posit that in war-torn times, children are forced to adjust out of necessity for survival. This experience develops the idea of a dangerous world where no one can be trusted and therefore prompts children to be the aggressor rather than the victim (Sims, Hayden, Palmer & Hutchins, 2000, p. 41). According to Vazquez there are many conditions that fit the general description of PTSD. There are however differences in â€Å"depth, complexity and intensity† that require appropriate and often differing treatments (Vazquez, 2005). In Stephen’s case, the therapy method that worked for him involved deep self-reflection and existential therapy sessions with his counselor where he was able to open up and tell stories of his experiences and thoughts of his past and present, and dreams for the future (Roysircar, 2004). Effects and Treatment of Post Traumatic Stress Disorder It is important to remember that not every child who is exposed to or experiences trauma develops PTSD. Since the 1980’s there has been marked growth in the development of instrumentation in the measurement and treatment of PTSD in children. These assessment methods designed for children of different age groups include â€Å"structured interviews, questionnaires, self-report scales, inventories, and psychophysiological evaluation † (Alat, 2002) There are four major ways by which PTSD can affect children: cognitively,affectively, behavioral and physiological-somatically (Lowenthal, 1999; Alat, 2002). Cognitively, children experience fear at a possible repetition of the traumatic event. Some may even feel responsible for the traumatic event’s occurrence. There may also be confusion, academic and developmental problems, lowered IQ and diminished abilities in language and communication. In its affective effects, children with PTSD become emotionally fragile and are given to fits of outburst and anger. They develop low thresholds for stress and fear. They become nervous, compulsive and often feel a sense of futility. Behaviors can also become extreme. Affected children may become either very loud or very shy. It is not unusual for children to revert to juvenile behavior such as thumb sucking or regression in academic knowledge. They may also develop self-destructive behavior and become vulnerable to alcohol, drugs, and self-abuse. Children may also manifest PTSD in the form of physical sickness such as high temperatures, â€Å"vomiting and headaches†(Alat, 2002). There may also be instances of sleep and eating disorders, fatigue and â€Å"biochemical alterations in the brain† (Alat, 2002) Family members and teachers generally notice these symptoms first. At this time, it is important that both come together and develop ways of supporting the affected child. A school counselor may be able to help evaluate whether a child indeed has PTSD or not. Therapy with a professionally trained psychiatrist, psychologist, counselor or therapist is the treatment for persons diagnosed with PTSD. The methods employed however, may vary according to the severity of the disorder as may be observed in the individual. Majority of the suggested therapies that parents and educators are encouraged to employ with children suffering from PTSD are physical and social expression/reflection through group and one-on one interaction as well as play based therapies (Alat, 2002). This particular therapy however has encountered difficulties particularly after the 9/11 attacks and the idea that aggression addressed in the earlier stages will stave off future violent behavior. For example, a child who builds a tower of blocks and flies an airplane into them may be viewed as at-risk for future violence. This child’s behavior, in fact, may be a healthy and developmentally appropriate way to gain mastery over the child’s fears, anger, and confusion about Sept. 11. Smith and Reynolds (2002) decry this repression of a child’s possible â€Å"venting† or anger and state that instead of suppressing the aggression manifested by children at play, parents and educators should let children be within certain limits. As long as children do not cause harm to themselves, others or objects within their surroundings, it is best that they be allowed to express their anger and whatever negative feelings they have in a â€Å"therapeutic manner.† (Smith & Reynolds, 2002) Conclusion   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The researcher observes that while there is an acceptance and awareness of the existence of Post Traumatic Stress Disorder among children, there still seem to be a lot of confusion as to what are the indicators of such disorder as well as the methods by which it should be addressed and treated. While Lowenthal (1999), Alat (2002) and other psychologists have managed to simplify such symptoms in four main categories, it is also stated in most studies that childhood trauma does not necessarily result in PTSD. There is still a question as to how the average lay person may be able to distinguish between delayed PTSD and natural defiance and common anxiety. The researcher also noticed that several of the symptoms listed in determining PTSD can also be found listed as symptoms of other psychological disorders in the DSM IV. The only difference is that with PTSD, there is a requisite traumatic event that is supposed to act as a trigger for the disorder. Smith and Reynolds (2002) make a valid point as to how adult paranoia of events that could possibly happen could seriously hinder the coping mechanism of children and therefore cause more harm than good. Logic dictates that feelings left unexpressed often come out one way or another. Alat also makes a good suggestion in encouraging teachers /educators to help children express their feelings in group discussions. As adults benefit largely in group therapy, there is no reason why children should not be able to do the same. Recommendations   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Despite its many advancements in instrumentation and awareness, there are still many gray areas in how people can support and help children suffering PTSD. The researcher recommends that further studies be done with the objective of clarifying and further distinguishing PTSD symptoms from other psychological disorders so that those affected may receive the appropriate treatment.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The researcher further recommends that programs designed to educate teachers, primary care givers and parents in the impact of PTSD on children as well as the many ways they can help support the child’s treatment. Most of the child’s time is spent with family and school. It may perhaps speed up progress of therapy is extended beyond the time they spend with their clinical therapists.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   There is the observation that adults may feel fear at what they perceive to be early signs of violence and aggression. The very fact that this sort of thinking exists stands as proof that attention to educating the people in a child’s environment with regard to what is natural and not in children’s behavioral patterns must be emphasized. Constant communication between parents and other people their children interact with particularly in the period following a traumatic event may also be helpful in gauging any effects the vent may have had.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Children exhibiting changes in behavior must also be carefully observed. As in the case of little Johnny who suddenly developed a fear of elevators, there may just be something behind the changes in a child’s behavior. Forcing them to face fears without completely understanding the root of these fears may only cause irreparable damage. These are just a few things that psychologists and behaviorists must educate parents and the other people in close contact with a child possibly suffering from post traumatic stress disorder in. References Alat, K. (2002). Traumatic Events and Children: How Early Childhood Educators Can Help. Childhood Education, 79(1), 2+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5002498529 Foa, E., & Meadows, E. (1997). Psychosocial Treatments for Posttraumatic Stress Disorder: A Critical Review. 449+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5000413895 Lowenthal, B. (1999). Effects of Maltreatment and Ways to Promote Children’s Resiliency. Childhood Education, 75(4), 204+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5002315362 Mcnally, R. J. (2003). Progress and Controversy in the Study of Posttraumatic Stress Disorder. 229+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5002051892 Murray, J. B. (1992). Posttraumatic Stress Disorder: A Review. Genetic, Social, and General Psychology Monographs, 118(3), 315-338. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=96430362 Roysircar, G. (2004). Child Survivor of War: A Case Study. Journal of Multicultural Counseling and Development, 32(3), 168+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5012181947 Saylor, C. F., Swenson, C. C., Reynolds, S. S., & Taylor, M. (1999). The Pediatric Emotional Distress Scale: a Brief Screening Measure for Young Children Exposed to Traumatic Events. Journal of Clinical Child Psychology, 28(1), 70-81. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=81021655 Sims, M., Hayden, J., Palmer, G., & Hutchins, T. (2000). Working in Early Childhood Settings with Children Who Have Experienced Refugee or War-Related Trauma. Australian Journal of Early Childhood, 25(4), 41. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001127890 Smith, S., & Reynolds, C. (2002). Innocent Lost: The Impact of 9-11 on the Development of Children. Annals of the American Psychotherapy Association, 5(5), 12+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5002560442 Vazquez, S. R. (2005). A New Paradigm for PTSD Treatment: Emotional Transformation Therapy. Annals of the American Psychotherapy Association, 8(2), 18+. Retrieved November 21, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5011704316