Every community resource that meets basic life needs, promotes good health, and remediates health problems, should be equally accessible to individuals with and without developmental disabilities. Though the situation has continually improved in recent years, many people with disabilities still have difficulty obtaining the quality health care they need and deserve.
In response to this need, the Minnesota Governor's Planning Council on Developmental Disabilities provided funding for creation of the Health Care Standards Project for People with Developmental Disabilities. The project conducted jointly by Gillette Children's Hospital in St. Paul and the Minnesota University Affiliated Program on Developmental Disabilities at the University of Minnesota has produced two booklets aimed at improving the quality and availability of health care for persons with developmental disabilities. The first booklet, Quality Health Care for People with Developmental Disabilities: A Guide for Parents and Other Caregivers, was designed to aid parents, advocates, helpers, coworkers, and friends as they assist individuals with disabilities to obtain health care and maintain a healthy lifestyle. This second booklet, Quality Health Care for People with Developmental Disabilities: A Guide for Health Professionals, is aimed at improving health services by educating people presently training as health practitioners and persons working in community service programs.
The content of this booklet provides the basis for appropriate, comprehensive health care that should be reasonably expected for people with developmental disabilities in all communities. This publication contains information on health care needs of people with developmental disabilities and recommendations for health care practices adapted from accepted standards of health care for the general population.
Provision of quality health care for individuals with developmental disabilities is an important and complex issue, This booklet is only one step toward reaching the goal of equal access to the best possible health care for all members of our communities,
Richard A. Nelson
Deborah Plumb
Kathleen M. Pfaffinger
photo by Gregg Waterman
.'
Table of Contents
Preface
I. Introduction
Definitions
Current Service Delivery Trends
Health Care Services Delivery Issues
II. General Child and Adolescent Health Care
Health Supervision
Adolescent Health
Special issues for Children and Youth with Disabilities
III. Adult Health Care
IV. Nutrition
Atypical Feeding Capability or Eating Behaviors
Altered Route offending (Gastrostomy)
Abnormal Patterns of Elimination (Constipation)
Varying Caloric Requirements by Disability
Other Factors Affecting Nutrition
V. Reproductive Health Care and Sexuality
Gynecological Health
Sexuality
Reproduction and Contraception
Obstetrical Health
Sexual Vulnerability and Safety
VI. Dental Health Care
Treatment Planning
Examining Uncooperative or Frightened Patients
Prosthodontic Care
Orthodontic Treatment
Infection Control Practices for Dentistry
VII. Infectious Disease
Recommended Immunizations
Hepatitis B Virus (HBV)
Tuberculosis
Sexually Transmitted Diseases
Special Considerations for People with Developmental
Disabilities .
VIII.Chronic Health Conditions
Atherosclerotic Disease
Hypertension
Cancer
Diabetes
Epflepsy
Rheumatic Disease
IX.Additional information
X.Appendices
A. Immunization Recommendations
B. Client Education for identifying and Managing Minor
Illnesses
C. Selected Readings and Educational Materials
D. Community Resources
Acknowledgements
1. Introduction
During the past 20 years, the United States has witnessed substantial changes in the scope and nature of services to people with developmental disabilities. These important changes in philosophy and practice are mirrored in the recently passed Developmental Disabilities Assistance and Bill of Rights Acts. This legislation sets forth national goals for improving the lives of people in our society with developmental disabilities. At the forefront of our national agenda is a commitment to promote the independence, productivity and community integration of people with developmental disabilities.
The priorities of this Developmental Disabilities Act are also reflected in recent changes that have occurred in the provision of services to people with developmental disabilities in Minnesota, and in other states throughout the United States. These changes in services increasingly emphasize the development of living arrangements, employment opportunities, leisurerecreation activities, and learning and training experiences in regular community settings. Because of new attitudes and service strategies, literally hundreds of thousands of people with developmental and related disabilities now enjoy the benefits of community living.
With any significant change there are always a number of unintended complications, as well as benefits. One serious challenge faced by consumers, policy makers, and service providers is the provision and effective coordination of community health services for people with developmental disabilities. As people with developmental disabilities increasingly turn to community-based services for their health care, those services must expand their expertise and adapt their service approaches in ways that enable them to offer appropriate care that meets the needs of those new consumers.
To prepare themselves to meet that challenge, health professionals can familiarize themselves with the characteristics of developmental disabilities, with health care needs of this population, and with the applications of general health care standards to those with disabilities. This guide offers people who are training for health professions, and personnel in community service programs, a resource for beginning that preparation.
Definitions
The term "developmental disability" gained widespread use with the enactment of the federal Developmental Disabilities Act in 1970. The Act applies the term to specific ~
recipients of the legislation's funding, support and advocacy. A developmental disability is defined as:
Physical andlor mental impairment that is manifested before age 22, is likely to
continue indefinitely, and will result in substantial functional limitation in several major life
activities (e.g., self-care, receptive and expressive language, learning, mobility and independent living), reflecting the need for lifelong services. "
BY intent the definition does not contain specific
medical diagnoses, but refers to the FUNCTIONAL status of the individual. There are no uniform medical consequences of having a developmental disability. The individual's health care needs may be as unique as those of
any other person.
Within this broad category, clinical practitioners commonly see such conditions as autism, cerebral palsy, epilepsy, spina bifida, Tourette's syndrome, and mental retardation.
Autism is a condition of children, youth and adults that results in major disturbances
of communication, socialization and learning. Autism can occur without any known
associated metabolic or pathologic entity affecting the central nervous system.
Observed abnormalities include delay, arrest or regression in developmental rates;
atypical responses to sensory stimuli; absent or limited verbal communication; and incapacity to appropriately relate to people, events or objects. The condition has a prevalence of about 5 per 10,000 and occurs more commonly in males.
Intellectual development varies, but most individuals function in the subnormal range of mental ability.
Cerebral palsy is a non-progressive disorder of motion and Posture due to brain insult
or injury during the period of early brain growth. There is no single pathological etiology for this condition, and the majority of individuals probably have had a prenatal insult to the
integrity of the central nervous system. Cerebral palsy can also result from such perinatal
events as prematurity, asphyxia and intracranial hemorrhage. After the neonatal period, cerebral palsy can result from meningitis or head trauma. Characteristics of cerebral palsy include spasticity, hypotonia, abnormal motor movements and orthopedic deformity, occurring as individual deficits or in combination. The condition has a prevalence of approximately 1per 1000. Commonly associated conditions include epilepsy, learning disability or mental retardation, and strabismus. The extent of dysfunction is highly variable. ."
Epilepsy is a condition of the central nervous system in which abnormal episodes of
consciousness disturbance or involuntary motor movements occur. These episodes, generally called seizures, vary in frequency, clinical manifestations and severity. There is no single etiology. In the majority of individuals with recurrent or chronic seizures, the cause is unknown. In other situations, head trauma, intracranial infection or metabolic disturbance may have preceded the onset of seizures. Epilepsy is not invariably associated with any intellectual deficit. About 1 in 100 individuals have a history of seizures. Modern anticonvulsant medications can effectively manage and control seizures for most individuals with epilepsy.
Meningomyelocele (spina bifida) is a congenital defect in the closure of the spinal canal with a hernial protrusion of the meningeal sheath of the spinal cord. The cause is unknown, although the interaction of multiple genes (polygenetic expression) and such prenatal environmental factors as maternal malnutrition and exposure to certain chemicals
appear important. The overall incidence is estimated to be 1 per 1,000.
Individuals with meningomyelocele may have several associated problems that include hydrocephalus, vertebral and spinal column malformations such as kyphosis or scoliosis, loss of sensation and motor function to lower extremities, and urinary tract and bowel dysfunction. The number and extent of these problems is related to the location and size of the spinal cord lesion. Many people with meningomyelocele require services from multiple specialists and their health care requires careful coordination.
Tourette's syndrome is patterned involuntary movement of muscles or muscle groups that includes both motor and vocal tics. There are no definitive data, but estimates of prevalence range from .1 to 1.6 per 1,000. The age of onset is from 2 to 15 years of age. A multifactorial etiology is suspected including genetic and biochemical factors. Recent studies show an association between obsessive-compulsive behavior, attention deficit disorders, and Tourette's syndrome.
Mental retardation is the most common developmental disability and occurs in about 2
out of 100 people. There is no single cause of mental retardation. The term refers to significantly subaverage general intellectual function and adaptive behavior manifested
during the developmental period (childhood and adolescence). Adaptive behavior is the degree to which an individual meets standards of personal independence and social
responsibility for his or her age and cultural group. Both intellectual functioning and
adaptive behavior should be assessed using standardized measures. When the level of
intellectual functioning is greater than two standard deviations below the mean achieved by a peer group AND there are significant adaptive behavior deficits, a person is
often defined as having mental retardation.
Other related conditions can create the same compromises or special needs for
individuals as the preceding diagnostic conditions. These conditions include sensory
deficits accompanied by learning or physical limitations, multiple physical abnormalities,
or disorders of cognitive function. How well an individual functions determines the
impact of a developmental disability on daily living.
Official definitions of "developmental disabilities" are important to use in deter-
mining eligibility for services covered by the federal Developmental Disabilities Act and
various state statutes. In addition, a specific diagnosis within this generic category is
necessary for planning and providing services. It is important, however, to think of people with developmental disabilities, first and foremost, as people with ability. While they require some degree of special assistance to take advantage of our society's freedoms and opportunities, they are fundamentally more similar to the rest of the population than different.
Current Service
DeliveryTrends*
A 1987 monograph published by the Minnesota Governor's Planning Council on Developmental Disabilities entitled A "New Way of Thinking describes fundamental
changes in the way our society perceives people with disabilities and concomitant changes
in service delivery and organization for these individuals.These changes have important
implications for health services delivery as well, and several will be highlighted.
A new way of living: "There is a growing recognition that having a real home is as
important for people with developmental disabilities as it is for everyone else" (p. 22).
This recognition has led to significant shifts in residential services, known as DEINSTlTUTIONALIZATION. This trend is characterized by efforts to reduce the number of people in regional treatment centers and to increase community living options. Resources
include support for families so that individuals with developmental disabilities can live with
The material in the next two sections is adapted from a report published by the Minnesota Governor's Planning Council on Developmental Disabilities, A New Way of Thinking (1987), and the reader is encouraged to obtain a copy of this publication for a complete discussion of these issues. They are also portrayed in an award winning video production of the same title. Full citations and information on how to obtain these and other resources are listed in Appendix C.
their own families or foster families, supported independent living arrangements, or
semi-independent living arrangements in small group homes. Although further progress is needed toward the goal of community living, many people once institutionalized now live in home communities and seek health care in these communities as well.
A new way of learning: "When the institutional approach prevailed, young
people with developmental disabilities did not attend public schools; they stayed at
home, were admitted to state institutions, or attended special, private schools" (p. 10).
A shift begun in the late 1950s directs all children toward regular, public schools. The
Education for All Handicapped Children Act (P.L. 94-142), passed by the federal govern-
ment in 1975, mandates free and appropriate education in the least restrictive environ-
ment. This movement to include children with disabilities in their local neighborhood
schools and provide education in regular class settings is known as INCLUSIVE EDUCATION. The act also requires an individual education plan (IEP), developed by parents and an interdisciplinary team.
In 1987, the Education for All Handicapped Children Act was amended to include early
intervention for infants and young children. The new act (P.L. 99-457) also mandates a
family-oriented plan or individual family service plan (IFSP). Infants and young children with complicated health service needs necessitate that health providers work closely with the family and other service providers to develop a comprehensive and coordinated service plan.
Health Care Services
Delivery Issues
Individuals with developmental disabilities have the same basic health care needs
as the general population. As a group, however, they have a high incidence of health prob-
lems and disabilities which, if left untreated, could significantly decrease their potential
for development and adjustment.
The extent of health services needed varies with each individual. For example, young children with developmental disabilities always require a thorough evaluation, and many
will need specialized diagnostic and rehabilitative services. This early intervention is critical
for reducing adverse long-term effects of numerous conditions.
Health care for people with developmental disabilities typically requires the cooperative efforts of multiple professionals and agencies. The participation in care or services by an increased number of providers contributes to the frequency or complexity of
treatment. It also challenges providers to maintain a coordinated care plan with consensus about treatment goals. Family members should be consulted and encouraged to actively participate in decisions regarding care. It is important to carefully coordinate specialized care with routine preventive health care. In some situations, a case coordinator may be needed to ensure services are appropriately arranged for and received by the individual.
A person with a developmental disabilities who also has an emotional or behavioral disorder presents a major challenge to the physician or therapist. Positive approaches to behavioral management are preferred, but must be adapted to the person's level of cognitive function. Excessive and often inappropriate use of medications to manage behavior disorders is a frequent concern in service programs.
Psychoactive medications, if used, must be prescribed and managed in the context of a
comprehensive treatment program that provides support for usual daily activities. Uni-
versity centers or specialized
Dan Romero* uses a wheelchair, although with help he can stand and walk a few steps. The first time Dan had a physical with his new doctor, the physician never had Dan get out
of the chair. She assumed Dan couldn't get up, and Dan felt too intimidated to suggest the doctor do the exam differently.
If the doctor had only asked Dan or his family, her patient could have received a more comprehensive and complete physical.
*Not real name
clinics may offer specific management suggestions and follow-along care.
People with developmental disabilities may experience barriers to receiving quality
health care. The frequency and extent of these impediments are related to the availability of
and access to services. Medical and other health care specialists do not practice in all communities especially in rural areas. Special transportation arrangements may be necessary. Inadequate medical supplies, funding of care, and durable equipment may also limit treatment options.
Physical accessibility of offices and other health facilities is a basic consideration
that is sometimes overlooked. In addition to entrances that accommodate wheelchairs
and other mobility aids, and elevators in buildings with more than one level, consideration should be given to accessible and conveniently placed rest rooms and water
fountains, adjustable exam tables and other equipment that can be positioned to facilitate exams and procedures for individuals with mobility impairments. It is also important that staff be trained to lift and position clients properly when this type of assistance is required.
Although most developmental disabilities are static conditions, some individuals experience increasing functional disabilities as they grow older. They may also acquire unrelated chronic diseases that compromise function. individuals with conditions such as
muscular dystrophy, tuberous sclerosis, neurofibromatosis and progressive metabolic
disorders will experience distinct loss of functidh that requires increased care over
time. In these situations, providers must be alert to the changes in the individual's
physical and functional status. Health care requirements and all aspects of daily living
should be carefully evaluated so that needs continue to be met. Major interventions,
including new programs or intensive medical treatment, should be planned through an
interdisciplinary process involving key providers, extended family or a client advocate, and the affected person whenever possible if the condition is progressive and death may be likely, the extent of life support should be discussed with all Concerned parties. There should be every attempt to resuscitate an individual after respiratory or cardiac arrest unless another decision previously has been made. A deliberate decision should be reached through an appropriate process prior to such a catastrophic event.
II. General Child
and Adolescent Health Care
A child in good health has the potential for optimal physical, intellectual and emotional
growth and development. In addition, a child's chances for becoming a functional and
productive adult are enhanced when health is optimal throughout the developmental
period. There is no other period in the life span where the rewards of health supervi-
sion and preventive care are as great.
Health Supervision
Every child should receive regular health, growth and developmental assessments by trained health professionals. The American Academy of Pediatrics suggests the follow-
ing schedule for health supervision visits, and notes that some children require more
and others less care depending on individual health needs or conditions. These guide-lines are the best current estimates of average needed services.
Birth and during acute illness: Health supervision visits should occur at birth and during acute illnesses.
Infancy period (up to 2 years): Health supervision visits should be made at least five times during the first year and three times during the second year.
Preschool period (2 to 6 years): Health supervision visits should be made at least three times during this period, at about 2 years of age, 3 years of age, and again at 5 to 6 years.
School age (6 to 18 years): Health supervision visits should be made at least four
times during this age span. Health supervision is more than a "well child" visit. Supervision provides:
Diagnosis and treatment of minor illness and conditions that families "save up" for
routine health visits.
Early diagnosis and treatment of illness and conditions not obvious to family members.
Assessment and management of chronic conditions.
Counseling for the child and family regarding such topics as development, nutrition and
injury prevention. Health supervision visits should include the following activities:
Review and discussion of the child's health and developmental history since the last visit.
A complete examine of the child. Record any variations from normal.
Recommended immunizations. (See Appendix A)
Frank discussion of the child's physical, mental, and behavioral status and problems. Based upon the results of the examination or concerns raised by the child andlor parent or guardian, a variety of subjects may arise that will need discussion and counseling.
Written instructions concerning the child's specific needs, including information to promote health such as dietary recommendations and treatment recommendations for any special health problems.
Adolescent Health
Adolescence is characterized by rapid physiological and psychological change. Health professionals must have the knowledge and technical skills required to manage concerns
relating to sexuality, family and peer relationships, risk-taking behaviors and self-image.
Adolescents with disabilities are an especially vulnerable group because their disabilities are compounded by the biological and psychological changes of puberty. Many chronic health conditions impose activity andlor dietary restrictions inconsistent with the adolescent need for autonomy or desire to be like peers. Other conditions may impede the development of satisfactory self-image or self-esteem.
Adolescents with disabilities and their families are likely to have multiple needs. The
services of professionals in such disciplines as nursing, psychology, social work, family
counseling, and medicine are recommended. To provide meaningful and
comprehensive health care to adolescents, the health assessment must determine the:
Stage of physical development.
State of Psvchosocial development and function.
Presence of abnormalities requiring treatment.
Presence of risk factors for future disease.
Existence of minor problems that may have major meaning to the adolescent.
Consequences of the adolescent's lifestyle and environment.
Health knowledge, behavior, and educational needs of the adolescent.
Special Issues for
Children and Youth
with Disabilities
Children and youth with developmental disabilities may or may not have special physi-
cal health care needs. In uncomplicated mental retardation or autism, for example, the health status of the individual may be unremarkable. In these situations, the health care
practitioner should follow standards and guidelines proposed for the general population. Most individuals with developmental disabilities, however, will need some adaptation in health services to accommodate the particular nature of their functional limita-
tions.
Some children with atypical development or behavior may be difficult to examine due
to inattention, oppositional reactions, or apprehension, and, in some cases, physical deformitv. These difficulties may be &ompounded when a non-verbal child or youth
cannot provide information about symptoms of an acute illness. Physician and other
practitioners generally find that a thorough interview with the parent or primary caregiver
provides an adequate history of illness. A relaxed, minimally threatening physical examina-
tion then provides necessary diagnostic information. It is important to know the child or
youth's approximate level of intellectual functioning so that there is neither an underesti-
mate or overestimate of the child's understanding. The professional may ask the family
to prepare the child by explaining andlor demonstrating the exam before the appointment.
Professionals should discuss with the family the preferred way to address, approach and
communicate with the child to reduce anxiety.
Children and youth with multiple disabilities present a special challenge. Their health
conditions often require sophisticated medical technology for diagnosis and manage-
ment. They may require the services of a team of health providers, including several
specialists.
Health providers need to recognize how a chronic illness, in addition to a developmental disability, affects growth and development.
Finally, there is a need to understand the stresses with which families must cope.
Complex care regimens place special demands on families and caretakers, and the high
cost of this specialized care can be a financial burden. Health care providers must carefully assess family functioning, keeping demands of care within a tolerable range while supporting individual and family autonomy.
III. Adult Health Care
Adult health needs are less predictable than a child's and there is no uniform agreement
on intervals between exams. The frequency of health visits should be determined by
individuals needs. Similarly, the content and focus of health care depends on the person's
age and specific concerns.
Regardless of age, evaluation of the adult follows the same series of steps:
Collect data from the history, the physical examination and the laboratory.
Organize and synthesize the data to produce a list of problems or diagnoses that
determine the need for the further evaluation or suggest initiation of specific therapy.
Review efficacy of therapy and validity of diagnosis over time.
Collect further data as needed as new problems or diagnoses arise.
Adults should receive routine preventive health services that are comprised of the following components:
Periodic preventive health services, including history (medical, social and occupational history and lifestyle inventory), physical examination, and laboratory tests appropriate to age and health risks. The examination should include blood pressure measurement and management when abnormal; simple screening for visual and auditory acuity and dental status, with referral or treatment of abnormalities; glaucoma
screening for individuals at risk; cancer screening at appropriate ages such as inspection of skin, examination of the stool for occult blood, breast examination and pap smears for women, mammography for those woman over 40 and testicular exam for men; and
cholesterol screening.
Nutritional assessment.
Patient education on such topics as breast self-examination, testicular self-exam, nutrition, exercise, accident prevention, and substance abuse (alcohol, tobacco, and drugs).
Psychosocial needs assessment, with referral when indicated, to social and mental health services.
Contraceptive information and services when appropriate.
IV. Nutrition
The body metabolizes nutrients for tissue formation, growth, repair and mainte-
nance. These nutrients are carbohydrates, proteins, fats, vitamins, minerals and water.
In total, 40 known nutrients play an essential metabolic role.
Nutritional requirements vary during the life cycle. The needs are greatest during periods of rapid growth and decrease as growth slows or ceases. Periods of peak nutritional needs come between birth and 2 years of age and at adolescence. Direct careful attention to these growth periods to assure adequate nutrients and energy to promote optimal growth, development, and health.
The nutritional needs of people with disabilities have not been shown to be different from typical population groups with regard to the Food and Nutrition Board's Recommended Dietary Allowances. However, people with developmental disabilities are at a higher risk for nutritional problems due to a high incidence of eating disorders and their frequent reliance on others for food selection, preparation and availability.
People with developmental disabilities require basic nutritional screening and assessment, preventive services, treatment for identified conditions, and follow-up services in orders to receive appropriate health care.
Atypical Feeding
Capability or Eating
Behaviors
Individuals with physical disability involving oral-motor dysfunction are at higher risk for inadequate intake. Uncoordinated sucking andlor swallowing is frequently observed in neurologically compromised infants. Other young children may consume fluids relatively well, but be unable to chew or swallow solid foods. The converse may also be true.
Swallowing may be complicated by aspiration of foods or fluids into the lungs, or reflux of stomach contents up the esophagus with resulting vomiting or aspiration.
Parents or caregivers may not detect mild abnormalities in feeding capability. In these situations, careful monitoring of weight (and body length in a child) and physical examination may be required to detect nutritional deficiency.
Abnormal eating behaviors are observed in greater frequency in people with developmental disabilities than in the general population. Clinical problems such as hyperactivity, anorexia, rumination or recurrent vomiting may be associated with poor growth and weight loss in the absence of any anatomical or biochemical defect. One should carefully evaluate these conditions to determine if any specific environmental factors induce or aggravate the undesirable behavior. Environmental control, including careful planning of the diet and meal supervision is often the most appropritate management strategy.
Altered Route of Feeding (Gastrostomy)
Some children and adults require an alternative feeding method due to inadequate caloric intake or recurrent aspiration. An infant whose eventual feeding capability is unknown may require a feeding tube through the nose or mouth into the stomach to deliver formula. If the feeding deficit appears to be indefinite, a "permanent" gastrostomy may be surgically inserted through the abdominal wall. Subsequent management of feeding should be under the direction of a physician and nutritionist. Some individuals, especially those with progressive muscular dysfunction, might do well with night-time continuous drip nasogastric feedings, which frees them and their caregivers to use waking hours for other activities.
Abnormal Patterns of Elimination
(Constipation)
Inactive or immobile individuals and people with neuromotor difficulties can have a decreased frequency of bowel elimination. Poor fluid intake and a diet deficient in bulk or
fiber will also contribute to constipation, a common occurrence in people with neuromotor difficulties. Diet modification is generally the first approach to managing constipation.
Medicinal stool softeners or laxatives also may be necessary.
Varying Caloric Requirements by Disability
Age, body size and energy expenditure determine daily caloric requirements. Relatively inactive people may need fewer calories whereas the opposite is true for very active individuals. There is no precise clinical method for calculating the caloric requirements of an individual with a specific disability other than through serial weight measurements and
dietary analysis.
Other Factors Affecting Nutrition
Food choice and preparation is determined by several factors. Most people make food choices based upon their eating habits and preferences, and on food costs. Limited income, poor food selection habits, and a lack of cooking skills can contribute to poor nutrition. These characteristics may be special problems for individuals with disabilities who
live independently, Nutritional education and reinforcement of healthy practices are essential in these circumstances.
V. Reproductive Health Care and Sexuality
Reproductive health services should be an integral part of the comprehensive health services provided for both males and females. The examining physician or nurse
practitioner should provide a full range of reproductive health care, including information and education about health maintenance, developing and changing sexuality, contraception, genetic risks of reproduction, and specific medical and surgical conditions related to gynecology. Health practitioners should teach breast self-examination to women, and testicular self-examination to men. In addition, practitioners should make each woman and man aware of common sex-related health risks for various times of their lives.
Overall health care should include a recognition of sexual, psychological and social needs. The practitioner should identify areas of difficulty and, when necessary, involve available community services for patient and family support, such as sexuality education and contraceptive services.
Women should have a gynecologic examination atleast by age 18, and routinely thereafter. Sexually active women should have periodic examinations regardless of their age. The frequency of such an examination depends on the woman's lifestyle and the risk of disease at various times of her life.
Women should be adequately prepared for gyneco- logical exams. .Such. preparption might include description of the procedures using pictures andlor models, and relaxation techniques. For some women with developmental disabilities, a thorough gynecological exam may take extra time. A longer appointment may be necessary to accommodate special needs.
Sexuality
Unless there is contradictory evidence, one should assume that sexual function (including sexual intercourse and masturbation) and reproductive capability (fertility) are normal regardless of mental age or physical disability. Some individuals with disabilities have delayed onset of puberty which may reflect inadequate gonadal function. When appropriate, an endocrinological evaluation should be undertaken if there is a suspected clinical problem.
During recent years there has been considerable emphasis on providing adequate sexuality education within the scope of a person's understanding in order to encourage good personal hygiene, appropriate behavior in individual and congregate settings, and to limit sexual vulnerability.
Reproduction and Contraception
Adolescents and adults with mental retardation have several special reproductive concerns.
In any circumstance when a person with mental retardation lacks the knowledge or judgement to make personal decisions regarding reproductive care, there is a need for personal advocacy on his or her behalf. Parents often provide that advocacy for minors. When the person reaches adulthood, the parent may obtain permission to continue in that role. The competence of the young person to make independent decisions may involve a determination by a court of law.
Comprehensive health care should include contraceptive services. Men and women should receive education, counseling, and referral to screen, detect, prevent or treat a variety of conditions with the objective of achieving and maintaining a state of good reproductive health. All people desiring contraceptive advice or techniques should be given information, methods or medication consistent with sound medical judgment and compatible with their personal convictions and capabilities.
These reproductive health services have two important functions: 1) to identifi by history or examination, factors that affect or limit contraceptive choices, and 2) to provide preventive health screening and counseling.
Woman using hormonal contraceptives and intrauterine devices (IUDS) are at higher
risk for certain complications, and complete annual examinations are recommended.
Healthy women using other methods of contraception require less frequent evaluations. Whenever sterilization is considered, the guardian or conservator must generally obtain court permission to perform the medical procedure. Surgical sterilization is considered an irreversible procedure regardless of whether the operation is pertion of each woman's special formed in a man (vasectomy) needs-medical, emotional and or woman (tubal ligation). educational-helps promote
The availability of medical quality obstetric care, contraception, and the recogonition that training and appropriate supervision can provide satisfactory menstual care in almost all situations has eliminated hysterectomy as a procudure for either contraception or menstual hygeine.
Obstetrical Health
Every woman should have a comprehensive program of obstetric care that begins as early as possible in the first trimester of pregnancy (preferably before conception, when pregnancy is anticipated), and extends through the postpartum period. Early diagnosis of pregnancy and risk assessment are important to establish the appropriate management plan. Consideration of each woman's special needs-medical, emotional and educational-helps promote quality obstetric care.
A comprehensive range of obstetric health services should be offered. These services
include medical, nursing and social work care, as well as nutrition and general health
education. When primary providers are unable to offer comprehensive services, they should make appropriate referrals to community resources.
When an unwanted pregnancy occurs in a woman with mental retardation, health care providers should follow established guidelines. If the court previously has found a woman
to be incompetent for her own care and she has a guardian or conservator, the court would likely find the woman unable to adequately care for a child. In circumstances where the competency of the woman to parent is less clear, and especially when the woman expresses her desire to carry the pregnancy forward and parent the child, social and public health nursing services should provide very close family supervision to assure that the needs of the woman and child are appropriately met.
Sexual Vulnerability and Safety
Individuals with disabilities may be more vulnerable to unwanted sexual advances or attacks. Some may have difficulty distinguishing inappropriate behavior, while other individuals may be physically vulnerable. In addition, offenders may think a person with a disability is less able to report or talk about an assault.
Periodic individual and peer-group education, as well as monitoring are necessary to reduce this vulnerability. Health providers should also encourage frank discussions about sexual vulnerability and safety with clients and their parents or caregivers. Aspects of the physical exam may include touch that is confusing to some clients. It may be necessary to help them distinguish what may be appropriate in that context that would not be in others.
Finally, service providers should be alert to any indications of sexual abuse. As with physical abuse, professionals are required to report suspected sexual abuse of a child or vulnerable adult to local protection or law enforcement agencies.
VI. Dental Health Care
Dental health needs of people with developmental disabilities require special attention and related adjustments.
Satisfactory oral hygiene has been neglected in many people with disabilities. For some, physical limitations may make self-care difficult. Some children and youth are actually sensitive and without persistent training there is a strong disincentive to brushing. Others may not be motivated to maintain adequate oral hygiene. In addition, limited funding of dental care and services in many communities may present problems.
All programs that serve children, youth and adults with disabilities should have a dental health component. Promoting oral health through outreach, assessment, dental health education and Preventive services should be a priority to minimize remedial care and to maintain satisfactory oral function. Every person should have a source of ongoing dental care.
As primary care providers, dental personnel should be fully cognizant of each patient's medical, physical and emotional condition. The patient with a disability may have a variety of factors to consider in planning dental care. The "modifications" needed to treat a dental patient with developmental disabilities are quite often no more than a thorough patient assessment, with extra time to perform clinical procedures. in addition, home care recom-
mendations and expectation may need to be adjusted to levels realistic for the individual's condition and capabilities. For instance, a tooth brush may need to be modified to make it easier to grasp.
Although many dentists treat people with developmental disabilities, pediatric dentistry is a dental specialty that specifically includes the treatment of people with disabilities. By definition, pediatric dentistry includes the care of special patients beyond the age of adolescence who have mental, physical, andlor emotional problems as well as the care of children. Health professionals and clients seeking a dentist who is prepared to treat
people with developmental disabilities can call their local dental society.
Treatment Planning
To formulate a treatment plan, clinical data from a thorough extraoral and intraoral
examination, dental charting, periodontal charting, orthodontic assessment and radio-graphic survey is needed.
To accurately integrate preventive services (scaling, polishing, fluoride use, plaque control, nutritional counseling andlor placement of sealants) into the treatment plan, practitioners should be aware of any limitations a patient's disability may place on the ability to receive treatment, While most routine procedures and education remain the same as for patients without disabilities, special consideration should be given to any cognitive or sensory difficulties that the disability creates, and appropriate adjustments made to accommodate the understanding of the patient. This may include demonstrations with models or illustrations, or allowing extra time to explain procedures.
Examinating Uncooperative or Frightened Patients
Dental hygienists and dentists frequently cite difficulties in examining uncooperative or frightened patients as the primary barrier to serving people with developmental disabilities. While reassurance, patience and painless technique can often alleviate anxiety, some situations may require some degree of sedation. It's possible that dental treatment may require general anesthesia that necessitates specialized out-patient or impatient facilities. While routine physical restraint is NOT recommended, some patients may need to have a stabilizing restraint to limit movement during dental procedures. These may include hyperkinetic patients, or those with spastic or athetoid cerebral palsy.
Prosthodontic Care
In the past, social and dental practice relied more frequently on removal rather than definitive restorative care. Therefore, a significant number of older people with developmental disabilities are completely or partially edentulous. Some individuals have arbitrarily beerl judged unable to use dentures and related appliances, and these devices have not been prescribed.
It is now recognized that dentures may be appropriately worn by many adults with
mental retardation and other disabilities in order to promote a normal diet and facilitate
intelligibility of speech. All edentulous individuals should be evaluated for the potential
use of dentures. Special attention should be given to educating patients and caregivers on proper use of dentures and related appliances.
Orthodontic Treatment
Orthodontic treatment is generally indicated when some significant functional improvement will occur as a result of treatment. Successful orthodontic treatment necessitates adequate oral hygiene during the treatment period. In severe cases orthodontic treatment and oral surgery may be necessary to correct a malocclusion or other deformity.
Infection Control Practices for Dentistry
Infection control practices are an essential element of dental health care provision. Due to the nature of many dental procedures, the risk of transmission of infectious disease is possible if precautions are not taken. Readers desiring more infcxmation on infectious disease control should consult The Centers for Disease Control recommendations (1986).
VII. Infectious Disease
Recommended Immunizations
The most commonly recommended immunizations include: diphtheria-tetanus-pertussis (DTP), polio, measles, mumps, and rubella. Appendix A presents a normal schedule of immunizations for children, as well as recommendations for adult immunization. Several factors that influence recommendations concerning vaccine administration include age-specific risks of disease, age-specific risks of complications, ability of individuals of a
given age to respond to the vaccine(s), and potential interference with the immune response by passively transferred maternal antibody.
Hepatitis B Virus (HRV)
The onset of acute hepatitis B is generally insidious, Clinical symptoms and signs
include various combinations of anorexia, malaise, nausea, vomiting, abdominal pain, and
jaundice. Skin rashes, arthralgia and arthritis can also occur. Overall fatality rates for
reported cases generally do not exceed two percent. The incubation period of hepatitis B is long, generally 45-160 days (average 60-120),
It is not uncommon to find a higher percentage of group home residents to be chronic
asymptomatic carriers of hepatitis B, although the rate varies among communities. If
there have not been any recognized cases of hepatitis B within the last 10 years in a
facility, there is probably no need to vaccinate staff or residents. if clinical hepatitis B is recognized, consider screening staff and residents and vaccinating those who are susceptible. In larger facilities, it is possible to separately evaluate units that care for more aggressive or self-injurious people and screen the staff and residents of those
particular units for hepatitis B carrier status. With that knowledge, decisions can be made
regarding the need for vaccination in individual units. The risk of hepatitis B varies from one location to another. Check with your state or local health department for current recommendations for your area.
Tuberculosis
Tuberculosis remains a significant public health problem because of its communicability and serious health implications if left untreated. Due to the persistence of tuberculosis in the United States, it is recommended that all communities provide at least a minimum level of tuberculosis services. These services should include tuberculosis screening, contact investigation ,and home care visits for patients on medication. The use of these services
in group living arrangements should be based on the prevalence of tuberculosis in the community and the diverse histories of residents.
Sexually Transmitted Diseases
Sexually transmitted diseases (STDS) vary in causative agent, symptomatology, and treatment. To reduce the risk of STDS, those who are sexually active should:
Avoid multiple partners, anonymous partners, prostitutes and other people with multiple sex partners.
Avoid sexual contact with people who have a genital discharge, genital warts, genital herpes lesions or other suspicious genital lesions.
Avoid oral-anal sex to prevent enteric infections.
Avoid genital contact with oral "cold sores."
Use condoms and diaphragms in combination with spermicides.
Have a periodic examination for sexually transmitted agents and syndromes if at high risk for STD.
Accurate identification and timely reporting of sexually transmitted diseases is an integral part of a successful disease control. All clinicians, health facilities and laboratories should report within 48 hours, STD diagnoses and positive STD laboratory results to local or state health departments according to established policy.
Special Considerations for People with Developmental Disabilities
The recognition of infectious disease is dependent on the accurate assessment of signs and symptoms. Signs are physical changes that are observable by a person other than the ill individual. They include changes in skin color, rashes, swelling or differences in stamina and physical function.
Symptoms are the subjective feelings an ill person may have that are not obvious to
the observer. Symptoms include pain, dizziness, mild weakness, or internal discomfort such as abdominal cramping. People with developmental disabilities, as well as family members or caregivers, should be taught to recognize changes that may signal the onset of an infectious disease. Health providers should emphasize the value of prompt evaluation and treatment. Discomfort, cost or complexity of care, as well as unfavorable outcomes, can be avoided by teaching clients the importance of prompt evaluation. Further information for client education is provided in Appendix B.
VIII. Chronic Health Conditions
In addition to medical treatment, comprehensive health care for children and adults with chronic illness or disability must include social, psychological, educational and vocational services as appropriate. Social and health services in rehabilitation and chronic care are inextricably related.
Early assessment of the clinical aspects, functional status and social components of each person's problem is an integral part of comprehensive health care. Failure to determine the causes and evaluate the effects of chronic illnesses and disabilities often results in recurring hospitalization, progressive deterioration of mind and body, and increasing
dependence. The financiemotional and social impact can be catastrophic, particularly in children for whom proper early assessment can affect the extent of disability, with all its consequences, for an entire lifetime.
Each person with chronic illness or disabilities should have access to programs designed to bring or restore the best physical, psychological, vocational and social functioning possible within the constraints imposed by the illness and social setting. Continuing programs should be available so that all gains can be sustained and extended.
Atherosclerotic Disease
The incidence of atherosclerotic cardiovascular disease reaches substantial proportions beyond age 45 in men and 55 in women. This class of disease constitutes the most frequent cause of short stay hospitalizations, and the highest costs per admission. The chances of an American male developing some clinical manifestation of atherosclerotic cardiovascular dis- ease before the age of 60 are still close to one in three. Atherosclerosis development has been associated with various risk factors. Since risk factors are often multiple and clearly synergistic, a comprehensive strategy of intervention is mandatory and should address:
Weight
Blood lipids.
Hyperglycemia and diabetes mellitus.
Hyperuricemia,
Hypertension.
Cigarette smoking.
Physical activity.
Clinical presentations of chronic coronary heart diseasemay include angina pectoris,heart failure, dysrhythmia orsystemic embolization. To reduce the risk of sudden,unexpected death andlor acute myocardial infarction, it is important to educate the public in detecting symptoms and signs and in modifying risk factors. Be aware that cigarette smoking, hypertension, hypercholesterolemia, severe obesity, diabetes mellitus, positive family history, and especially the presence of more than one of these risk factors, increases the risk of coronary artery disease.
Hypertension
Control of high blood pressure begins with detection and requires continued surveillance, Health care professionals are strongly encouraged to measure blood pressure at each patient visit. Individuals without regular contact with the medical care system should have their blood pressure measured at least once every two years.
Successful therapeutic intervention and follow-up begins with an assessment of patient readiness to control blood pressure and learn related behaviors. The patient's prior health practices and experiences with following health regimens should be considered along with physical, mental and emotional capacities to adjust to recommended changes.
Effective treatment of hypertension can be achieved through the use of anti-hypertensive drugs andlor nonpharmacologic approaches. Examples of the latter include:
Reducing weight.
Modifying sodium intake.
Moderating alcohol consumption.
Avoiding tobacco.
Exercise.
Cancer
Cancer is the second leading cause of death for Americans, surpassed only by cardiovascular diseases. Early detection and preventive measures, sometimes suc-
cessful in reducing the incidence and severity of cancer, include:
Reducing and ultimately eliminating cigarette smoking.
Including proctoscopic examinations in annual checkups for those over 50
years of age.
Examining testicles as a monthly male practice.
Examining breasts as a monthly female practice.
Having mammograms for women 40 and older.
Taking pap tests for all adult and high-risk women.
Avoiding excessive sun.
Diabetes
Diabetes is a chronic health condition caused by lack of insulin or the inability of
the body to use insulin.
The goals for management of patients with diabetes are:
(1) improved treatment of diabetes to delay or prevent complications, (2) early detection of complications, and (3) prompt and appropriate treatment of complications once they have been recognized.
The most common complications of diabetes are visual impairment, adverse outcomes of pregnancy, foot problems, kidney failure, acute hyperglycemia with ketoacidosis,
increased risk of hypertension and cardiovascular disease.
Hypoglycemia occurs when the rate of glucose entering the circulation does not keep pace with the utiliza tion of glucose by the peripheral tissues. The most common causes of hypoglycemia are excessive insulin, inadequate food intake, sustained physical exertion, and drugs.
Adherence to the following guidelines will assist in preventing hypoglycemia:
Ensure correct technique of insulin injection and rotation of sites.
Adhere to regular mealtimes and snacks as recommended.
Correctly interpret results of home blood glucose and urine tests.
Substitute oral liquid containing carbohydrates when food intake is reduced due to illness.
Eat a snack before engaging in some forms of exercise.
Adjust insulin dosage only according to physician's guidelines.
Give correct amount of insulin.
Epilispy
Epilepsy is a condition when a person has had at least two seizures at separate times during a lifetime. Prompt diagnosis and treatment are essential for the person experiencing a first seizure. Although control of seizures is paramount in the treatment of epilepsy, it is only
part of the treatment. The behavioral, social and economic consequences of uncontrolled seizures are enormous. Substantial amounts of emotional support involving a team of
nurses, social workers, vocational counselors, and other health professionals are often
necessary.
Rheumatic diseases
Rheumatic diseases fall into two broad categories: systemic rheumatic diseases and regional rheumatic diseases. Systemic diseases include rheumatoid arthritis, Systemic lupus erythematosus, scleroderma and polymyositis. Those affected are chronically ill, have intermittent and remittent easy fatiguability, and often suffer stiffness and generalized weakness. Joint pain and deformity are often features of these diseases. But the cardinal feature is the pervasive sense of being sick for prolonged periods. These systemic rheumatic diseases affect approximately three percent of the population.
Conversely, people with regional rheumatic diseases are basically well. They suffer
from pain and functional restriction in a single muscuIoskeletal region. Examples
include low back pain, neck pain, tennis elbow, shoulder pain (i.e., "bursitis") and carpal
tunnel syndrome. These illnesses, however, vary in intensity and tend to be self-limited. They usually remit, leaving some residual deficit. This form of arthritis may lead
to a need for joint replacement, especially hip replacement.
IX. Additional Information
While the standards of health care and many of the health services are the same for people with disabilities as the general population, there may be some special issues to consider in tailoring services to individual needs. This publication is designed as an introduction to these standards and service needs. The reader is referred to the resources listed in Appendix C for more in-depth information on selected topics. Appendix D is a list of community resources for services providers and/or their clients.
X. Appendices
Appendix A: Immunization Recommendations
RECOMMENDED SCHEDULE FOR ACTIVE IMMUNIZATIONS OF NORMAL INFANTS AND CHILDREN
RECOMMENDATIONS FOR ADULT IMMUNIZATION PRACTICE
The following recommendations apply generally to all healthy people.
Tetanus and Diphtheria Toxoids for Adult Use
All young adults should have completed a primary series of tetanus and diphtheria toxoids. People who have completed a primary series of tetanus and diphtheria immunization should receive a booster dose every 10 years.
Measles Vaccine
People born after 1956 should receive measles vaccine unless they have a dated
record indicating they have been immunized with live measles vaccine on or after
their first birthday; documentation of a physician's diagnosis of measles; or laboratory
evidence of immunity, if available. People vaccinated for measles between 1963 and
1967 should be revaccinated.
Mumps Vaccine
Most adults are likely to have been infected naturally and generally may be considered to be immune, even if they did not have clinically apparent mumps. Mumps vaccine may be given, however, if there is concern about susceptibility.
Rubella Vaccine
Women of childbearing age should be assured of immunity against rubella. This vaccine should be given unless patients have proof of immunity by laboratory evidence or have received the rubella vaccine after their first birthday. Pregnant women should not be vaccinated.
Influenza Vaccine
Although influenza vaccine is not recommended for universal immunization of healthy adults less than 65 years of age, considermion may be given to immunizing such
people who provide essential community services, including health care personnel who are
at increased risk of exposure to or transmission of infection. This latter group includes some people with disability who may be susceptible to debilitating pneumonia.
Pneumococcal Vaccine
Pneumococcal vaccine is particularly recommended for people over 65 years of age.
However, it may be considered for use in patients less than 65 based on individual physician judgment.
Hepatitis B Vaccine
Decisions on the administration of Hepatitis B vaccine should be based on risks of exposure. This varies from setting to setting. Check with your state or county health department for current, local recommendations.
VACCINATION DURING OR IMMEDIATELY PRIOR TO PREGNANCY
On the grounds of a theoretical risk to the developing fetus, live, attenuated-virus vaccines are not generally given to pregnant women or to those likely to become pregnant within 3 months after receiving vaccine(s).
Appendix 8: Client Education for Identifying and Managing Minor Illnesses
COMMON ILLNESSES: HOW TO IDENTIFY THEM AND WHEN TO CALL FOR HELP
An important task in facilitating health care for a child or an adult with a developmental disability, is being able to determine WHEN the person is sick and IF he or she needs to be evaluated by a health care provider. These may not be straightforward tasks. First of all, the decision is usually based on "second-hand" information; it's not your "ache", "pain", or "fever", but someone else's. Also the person may be unable to tell you that he or she does not feel well, or be unable to describe exactly what is wrong.
There are, however, general signs of illness; these signs usually involve a change. If you are alert to these, you can recognize many illnesses early in their course. Common changes are described in this section.
CHANGES IN TEMPERATURE
The normal body temperature is 98.6 F orally (99.6 rectally, and 97.6 axillary-taken in the armpit), although there are individual variations. When a person's temperature rises more than a degree above normal, it is a fairly reliable sign of illness. Unless the person has had some sort of heat injury (i.e., sunburn, sunstroke, heat exhaustion) it usually means an infection, However, a higher-than-normal temperature is a general symptom that occurs with many different types of infection. It could be caused by a cold, a bladder infection, an abscessed tooth, or some other condition. Other symptoms need to be considered in order to pin-point the source of the elevated temperature.
An elevated temperature should be treated by increasing the fluid intake in order to prevent dehydration. You may also want to give aspirin or acetaminophen (i.e., "Tylenol" or "Datrii") if the person seems uncomfortable. However, children and adolescents should only be given acetaminophen. Do NOT give them aspirin. Aspirin used by children and adolescents has been associated with an increased risk of Reyes syndrome, a rare but serious illness
A BELOW normal temperature (95o For below) can be the sign of a serious illness that
needs prompt attention by a physician, especially in infants and young children.
CHANGES IN APPETITE
While fluctuations in appetite are common, a rnarked decrease in appetite may indicate illness. A decreased appetite may also be accompanied by nausea or vomiting. Children may simply complain vaguely of a "tummy ache". Even when individuals lose their appetites, it is important that they continue to take fluids. If the person has nausea and perhaps vomiting as well, small amounts of clear fluids (one to two ounces per hour)
are often tolerated best.
Refusing to eat can be a serious problem for infants, since they rely on breast milk or formula not only for nutrition, but as their principal source of fluids. They can rapidly lose
weight and become dehydrated.
CHANGES IN AFFECT OR BEHAVIOR
A change in affect (mood) or behavior can be sudden and dramatic, or it can be subtle and gradual. While such changes are sometimes difficult to judge, they can be early signs of illness. For instance, you should suspect illness when a child (or an adult) who is usually good-natured becomes crabby, when someone who is usually talkative becomes quiet and listless, or changes requires that you when someone who is fairly know the person's "normal" active starts acting tired or behavior and are alert to any groggy. Analyzing these differences.
CHANGES IN APPEARANCE
Many of us have had the experience of just looking at someone and sensing that they are sick. Our hunch is most often based on the person's general appearance, especially his or her color. When someone is pale, flushed (red) or jaundiced (yellow), we sense that the
person is not well, and we are often right. Rashes can also be a visible sign of illness.
CHANGE iN BOWEL OR BLADDER HABiTS
Some sort of change in bowel or bladder habits is a fairly reliable indication of illness. This could be an increase or a decrease in frequency. It could also be the loss of bladder or sphincter control for someone who previously had control.
Diarrhea is the frequent passage of loose, liquid stools. It is a sign of bowel irritation. It
is frequently (though not always) caused by bacteria or viruses. This infection can be easily spread to others. Hand washing and careful handling or disposal of any soiled clothing or bedding is especially important when someone has diarrhea. Loose bowel movements can be normal for infants, but liquid or watery ones are not. Diarrhea in infants and young children can be serious, since it may lead to dehydration.
Constipation refers to bowel movements that are hard, dry and difficult to pass. It can frequently be treated without consulting a physician. Usually increases in fluid, fiber and activity are all that is can be the sign of a bladder required. Constipation, however, is another change that needs to be monitored.
Inconinence refers to the loss of bladder control in a child or an adult who typically has good bladder control. It can be the sign of a bladder infection. Increased urinary frequency may also be a sign of infection. On the other hand, a decrease in urinary frequency, or in the amoutn of urine being passed, can be a sign of dehydration.
CHANGES IN BREATHING
While people may have slight changes in breathing patterns with colds and fevers, rapid, noisy or difficult breathing usualiy signals problems that need prompt medical attention.
EVALUATING COMPLAINTS OF PAIN
In addition to the above changes, which are general signs of illness, a person may have specific complaints, especially of pain. Pain includes a variety of symptoms from a toothache, to a sore throat, to joint pain. All complaints of pain should be listened to and evaluated carefully. Some individuals have a high pain threshold, or an unusual tolerance for pain. There can be instances of broken bones or burns with no complaints of pain. This means you must be watchful for subtle changes and take what may seem like a minor complaint seriously.
Headaches can occur with stress, after a head injury, or with other symptoms such as
sore throats or fevers. Headaches are fairly common in adults and as long as they are
not frequent or severe, it is appropriate to treat them with over-the-counter medications
such as aspirin and acetaminophen. On the other hand, headaches in young children are rare and generally need to be evaluated by a physician. Except for minor bumps, all
head injuries should be evaluated by a physician.
Ear pain is often a symptom of an ear infection. It needs to be evaluated by a physician and frequently needs to be treated with an antibiotic,
A sore throat is a common complaint that frequently occurs with other cold symptoms such as a runny nose or a cough. It can be due to the same virus that caused the cold. There is no cure for viral illnesses such as the common cold, although increased fluid intake, throat lozenges, or salt water gargles may relive some of the throat pain associated with them. Some sore throats, on the other hand, are caused by the streptococcal bacteria (i.e., "strep throat"). This infection can and should be treated with antibiotic medications-both to relieve the symptoms and to prevent possible heart and kidney complications, Knowing the difference between a viral sore throat and a strep throat is not easy. A throat culture is
needed for a positive diagnosis. If the person has a sore throat accompanied by a fever,
swollen neck glands, enlarged and red tonsils, or white patches on the tonsils, you should contact a physician or health clinic so a throat culture can be done. Similar action should be taken if the person develops a sore throat after being exposed to someone with strep throat.
Tooth and jaw pain should always be evaluated by a dentist. Sores on the lips or in the mouth that do not heal within four or five days should, likewise, be evaluated by a dentist.
Stomach pains are fairly common in young children. They may be related to constipation, diarrhea, or sore muscles; or they may be the child's way of expressing stress. You should contact a physician if a child or adult has abdominal pain that is sharp; accompanied by nausea, vomiting or a fever; or persists more than two days.
Joint pains and muscle aches can occur with illness and fever or can be due to physical activity, especially if the activity is out of the ordinary for that individual. Consult
a physician if the joint or muscle feels hot to the touch, if there is any swelling, or if there
is a loss of movement in the joint or muscle because of the pain.
