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AUTISM FIRST STEPS
AUTISM DAILY NEWSLETTER
Thursday December 13, 2001
INDEX:
* Autism State Ambassadors Still Needed For Many States
* Exceptional Rodeo
delights kids
* Potent anti-bacterial
enzyme isolated
* Rights for those with special school needs
* Negotiators OK education bill requiring reading, math tests for
millions of
students
* Judge alters
Deptford special-ed settlement
* Recognizing Psychosis in Nonverbal Patients With Developmental
Disabilities
******************************
Autism State Ambassadors Still Needed For Many
States
Would
you like to make a direct difference in your state for individuals with autism?
Do you work with, love, or are a professional working with autism individuals?
Would you enjoy working with media, legislators, and autism professionals? Then
this may be just what you are looking for! Apply today and make a difference in
lives of individuals with autism! We have added many new State Ambassadors who
are eager to get started, they need your help! Each state needs to be
represented!
Contact: AutismAwakening@aol.com
For More Information: State
Autism Ambassador Project
******************************
Exceptional Rodeo
delights kids
Disabled children enjoy cowboy life
for day
By
GLENN PUIT
REVIEW-JOURNAL
Faced with riding a bucking bronco Monday at the Thomas & Mack
Center, 9-year-old Taylor Adams proved to be a natural. With his left hand in
the air and his black cowboy hat tilted slightly forward like a veteran
cowboy's would be, Taylor held on as the horse bucked him to and fro.
"He's in seventh heaven," Taylor's smiling father, Rod, said as he
videotaped his son's ride. The bronco, of course, was not real. But what was
real Monday was how much fun this was for Taylor, who has Down syndrome.
"He loves to play with the horses, and he loves to play in the dirt,"
Rod Adams said. "This is the greatest service you could ever give these
kids." Taylor was one of 50 children who had a ball at the Las Vegas arena
as part of the Exceptional Rodeo. For nearly two decades, the mock rodeo has
given disabled Southern Nevada children a chance to see what it feels like to
be a real-life cowboy. The Exceptional Rodeo calls for professional cowboys and
staffers of the PRCA to be paired up with each of the 50 children, who have
disabilities such as autism, cerebral palsy and other visual and hearing
challenges. Each child then is guided through a series of events including
rides on Wimpy the bull and Payday the bareback horse. There is also steer
wrestling, steer roping, barrel racing and a ride on a real pony. In the end,
each child is given a trophy and their pictures are put up on the arena's video
screens. Exceptional Rodeo founder Ruth Dismuke-Blakely said the event is an
annual opportunity for the Professional Rodeo Cowboys Association to give back
to Southern Nevada, which has been home to the National Finals Rodeo for 17
years. "It's a chance for the world to be reminded that kids are just
kids, regardless of whether they have special challenges or not,"
Dismuke-Blakely said. One of those kids was 14-year-old Brandon Little, a
student at John F. Miller School in Clark County. Brandon, who has multiple
disabilities and uses a wheelchair, was ecstatic when given a chance Monday to
pet the nose of a real pony. "See that smile?" said Little's teacher,
Woodie Mackie, as he referred to the grin on the teen's face. "I don't
need to interpret anything. That says it all." For autistic 6-year-old
Aedon Abbott, the steer roping was a thrill that couldn't be matched. Once he
had his rope around the neck of the creature, he pulled until the steer was
nearly on its side. "He's loving it," said Teresa Woods, who is
Aedon's teacher at Mesquite's Virgin Valley Elementary School. "It means a
lot to him just to interact with the other children." The Exceptional
Rodeo also means a lot to the rodeo contestants and staffers who help make it
possible. Barrel racer Kappy Allen said it warmed her heart to help Charlie
Sutton, 6, rope six horses and ride Wimpy. "It is the least I can
do," Allen said. With Allen's help, Charlie showed his proficiency as a cowboy
when, during the middle of the ride on Wimpy, he tipped his hat to a crowd of a
hundred or so watching the competition. "This puts everything else in life
in the proper perspective," Allen said. "We all get so caught up in
our own little worlds. After an hour of doing this, I thank God for what I
have." Dismuke-Blakely is convinced that, through the Exceptional Rodeo,
the PRCA is making a real difference in the youths' lives. "Cowboys are
real American heroes, and these kids look up to them like any other kid
does," she said.
http://www.lvrj.com/lvrj_home/2001/Dec-11-Tue-2001/news/17640629.html
******************************
The World's No.1 Science & Technology News Service
Potent anti-bacterial enzyme isolated
12:05 07 December 01
Greg Miller
An enzyme that kills the potentially dangerous bacterium Streptococcus
pneumoniae has been isolated by a US team. A nasal spray containing the
enzyme could be an effective alternative to conventional antibiotics, and could
help wipe out human reservoirs of the bug, the team says.Vincent Fischetti and
colleagues at Rockefeller University in New York isolated the enzyme, called
Pal, from a bacteriophage (a type of virus that infects bacteria) that targets S.
pneumoniae. Earlier this year, Fischetti's team isolated another
bacteriophage enzyme that kills streptococci, the bacteria responsible for
strep throat. The same method could also be used to find enzymes that kill
other bacteria. "Every bacteria has a bacteriophage system," Fischetti
says.S. pneumoniae lurks in the nose and throat of half the human
population and is a significant source of illness and death worldwide. It can
cause problems ranging from ear infections to potentially deadly diseases like
pneumonia and meningitis.
"Exciting opportunity"
In test tube experiments, Pal killed 15 strains of S. pneumoniae within
seconds of contact, but did not interfere with other, harmless, bacteria that
grow in the nose and throat, or with human cells. The enzyme also proved
effective against S. pneumoniae when applied to the noses of infected
mice.Fischetti is now planning clinical trials to test a nasal spray containing
Pal. He says the spray could be used periodically, say once a week, to keep
bacteria under control."I think it's an exciting opportunity for both
prevention and treatment," says Cynthia Whitney, an epidemiologist at the
Centers for Disease Control in Atlanta. She says the spray might be especially
useful in day care centres and nursing homes, where infections can spread quickly
from person to person.Fischetti says Pal would be more effective than existing
vaccines, which only protect against individual strains of S. pneumoniae.
And because the enzyme is so deadly, the bacteria do not seem to be able to
acquire resistance, as they have to antibiotic drugs, he says. Journal
reference: Science (vol 294, p 2170
http://www.newscientist.com/news/news.jsp?id=ns99991662
******************************
Rights for those with special school needs
By Sean
Flynn, Education Editor
A bill which gives improved legal
rights to those with special educational needs was agreed by the Cabinet
yesterday. In light of the Supreme Court judgment in the Sinnott case, the Bill
gives new educational rights to those aged 18 and over. But it is clear the
Government remains opposed to a constitutional referendum on educational
special needs along the lines favoured by Ms Kathryn Sinnott and other
campaigners. Government sources say experience in other countries shows that
legislation of the type agreed yesterday gives "cast-iron"
guarantees. The Sinnott case caused a furore because it said that only people
up to the age of 18 had an automatic right to a full primary education. The new
Education (Disabilities) Bill provides a statutory guarantee of education
services for people with a disability. It is seen as part of the Government
response to the recent Task Force on Autism which demanded stronger legal
guarantees. In practice, the Department of Education will, under the Bill, be
obliged to make appropriate special needs education available for all adults
with disabilities, if this is viewed as beneficial. There will also be an
explicit statutory obligation on health boards to ensure the best care and
personal development of these adults. There will be a new statutory duty to
provide for the continuing education of adults who are not capable of joining
the world of work. And, crucially, the development of the potential of such
adults will not be limited by age, according to the Bill. Last night, the
Minister for Education and Science, Dr Woods, said: "This Bill will
provide a clear and enforceable statement in law of the rights of children and
adults, who because of disabilities have special needs, and put in place a
statutory structure which will guarantee that education to them". The
Bill, he said, enshrines "the principles on which our education system is
based and copper fastens the guarantee of access to that system for all those
with disability, children and adults alike". The Bill also provides for: A
register of children with special needs;Education plans tailored to the
disabilities and educational needs of each individual;Involvement by parents in
the planning and ongoing review of their children's education; Mediation and
appeals structures;The establishment of a National Council for Special
Education as a dedicated statutory body with responsibility for ensuring the
aims of the Bill are met; New statutory duties on health boards to provide
assistance and services necessary for the education of children with special
needs. The Bill incorporates many of the elements demanded by the task force.
Its report was highly critical of the manner in which parents were often
routinely excluded from decisions about the education and/or treatment of
children. Government sources insisted the new Bill was not a response to the
Sinnott judgment but part of its overall commitment to people with special
needs. However, the Government will hope the Bill dampens public unease about
the Sinnott case and its implications.
http://www.ireland.com/newspaper/ireland/2001/1212/hom20.htm
******************************
Negotiators OK education bill requiring
reading, math tests for millions of students
Associated Press
GREG TOPPO AP Education Writer December 12, 2001
WASHINGTON (AP) - House and Senate negotiators have approved President Bush's
top domestic priority, finishing an education bill that would require millions
of students in grades three through eight to take annual reading and math
tests. For the first time, their scores could affect how federal aid to their
schools is allocated and spent. The bill, which also requires schools to come
up with plans to close the achievement gap between poor and middle-class
students, is virtually certain to win final passage in the next few days.
"These reforms mean new hope for students in failing schools, and new
choices for parents who want the best education possible for their
children," said Rep. John Boehner, R-Ohio, who chaired the House-Senate
committee that approved the final version of the bill. Bush on Wednesday
celebrated the agreement by inviting Boehner and the other top three House and
Senate negotiators to the Oval Office. "It's a good sign for the country
about what can happen when the leaders in Washington decide to work
together," said White House press secretary Ari Fleischer. The bill now
goes to the House and Senate for final votes. Lawmakers expect it to be on
Bush's desk by next week. While Boehner and others called the measure
groundbreaking, some observers complained about the final product. Bob Chase,
president of the National Education Association, called it "a tremendous
disappointment," saying it would force states to develop and give the
annual tests without enough funding from Washington - at a time when they are
being hit hard by a recession. "Considering this bleak fiscal climate,
these unfunded and underfunded mandates are irresponsible," Chase said.
"The broad policy goals are laudable, but the lack of support to states
suffering an economic decline is lamentable." Overall, the education bill
authorizes $26.5 billion next year for elementary and secondary education -
about $8 billion more than this year and about $4 billion more than Bush
requested, but nearly $6 billion less than Senate Democrats wanted. The annual
reading and math tests for all students in grades three through eight would
tell states which schools are effective. Those with persistently low test
scores would have to give some of their federal aid to students for tutoring or
transportation to another public school. More aid would flow to schools whose
scores don't improve for two years in a row, but if scores don't improve
afterward, a school's staff could be changed. States and school districts also
would get more freedom over how they spend federal dollars, but they'd be
required to send annual "report cards" showing a school's
standardized test scores compared to others locally and statewide. Also
included is Bush's signature reading program, which gives schools nearly $1
billion per year for the next five years in hopes that every student will be
able to read by third grade. The package is opposed by several groups that say
it will force states and school districts to spend millions they don't have.
Opponents include the National School Boards Association, the National
Conference of State Legislatures and the American Association of School
Administrators. Two senators - James Jeffords, I-Vt., and Paul Wellstone,
D-Minn. - said they would oppose the measure. They said Republicans' refusal to
include mandatory funding for disabled students made the bill incomplete. House
Republicans twice rejected the special education funding measure. "This
education bill requires our nation's schools to make major improvements within
a short time frame," Jeffords said. "This is a worthy goal, but one
which cannot be met unless the money is provided to give these schools the
technical assistance and expertise they so desperately need to carry out the
reform effort." A longtime special education advocate, Jeffords cited the
need for more school spending when he left the Republican Party last May,
handing control of the Senate to Democrats. Sen. Tom Harkin, D-Iowa, who
sponsored the special education measure, said the White House persuaded House
Republicans to block the measure to "punish" Jeffords. "I know
that the reason the White House is so adamantly opposed to this is that it will
make Jim Jeffords look good," he said. Jeffords himself said he thought
the administration opposed the funding because it wasn't a priority this year.
"They'll find it when they need it - about three years from now," he
said, referring to the 2004 elections. On the Net: Senate:
http://www.senate.gov House: http://www.house.gov
Copyright 2001 Associated Press. All rights reserved. This material may not be
published, broadcast, rewritten, or redistributed. 
http://www.brainconnection.com/SITEWare/2001/12/12/--dsa/7256-1713-Congress-Education.1stLd-Writethru.a0450..php3
******************************
Judge alters Deptford special-ed settlement
The district will not have to reimburse $50,000
in services not paid for by an autistic child's parents.
By Jake Wagman
INQUIRER SUBURBAN STAFF CAMDEN - A federal judge has rescinded part of his
order that the Deptford Township School District reimburse special-education
costs for the parents of a student with autism.On Nov. 2, U.S. District Judge
Jerome B. Simandle ordered that the school district pay $140,000 to the parents
of a pupil identified in court papers as H.B.But it turned out that some of the
services listed for reimbursement had not taken place."That's a $50,000
problem," Simandle said in court yesterday.The settlement was intended to
pay private learning centers and therapists used during the two-year legal
battle to create a program for H.B in the Deptford district.Simandle said a
misunderstanding of the definition of compensatory damages by the parents'
attorney had led the judge to order payment for $42,575 in therapies that had
not been performed and $6,900 for therapy that the school district had
provided."Certain matters were overlooked in previous decisions of this
court," Simandle said. "Clearly the district should not have to pay
for services not actually rendered."Lawyers for the Deptford school board
filed an affidavit last week from the district's director of special services,
Raymond L. Sherman. In it, he alleged that the parents' attorney, Jamie
Epstein, submitted "erroneous facts" to the court.Simandle ordered
that the district still has to pay $90,000 that the parents have spent, but he
called "grossly excessive" the payments to a Westville doctor that
Epstein said would total $2,100. According to Sherman's affidavits, such
evaluations typically cost no more than $500.In court yesterday, Epstein
defended the submission of the services in question by saying that if the
parents had been able to afford them, they would have been eligible for
reimbursement later."You shouldn't penalize this child because the parents
couldn't put up the cost of therapy," Epstein said.The case is an example
of how special-education cases can turn into prolonged legal disputes. The
federal Individuals With Disabilities in Education Act says every child is
entitled to a "free and appropriate education." When schools and
parents in New Jersey disagree on what that means for a student with special
needs, the case is brought before an administrative law judge in Trenton, whose
opinion can be appealed to federal court.Jake Wagman's e-mail address is jwagman@phillynews.com.
http://inq.philly.com/content/inquirer/2001/12/12/local_news/JSPECIAL12.htm
******************************
Recognizing
Psychosis in Nonverbal Patients With Developmental Disabilities
by Ruth Ryan, M.D.Psychiatric Times 
December
2001 Vol.
XVIII Issue
12 People with developmental disabilities (e.g., mental retardation, autism)
are vulnerable to the same psychiatric conditions as the general population
(Szymanski et al., 1990). Fortunately, for the most part, DSM-IV
criteria can be adapted easily to permit accurate diagnosis (Aman, 1991; Ryan,
1994b). However, these individuals may exhibit some unusual behaviors that seem
indicative of psychosis yet are actually almost never reflective of psychosis.
In addition, even when indications of psychosis are present, epidemiological
issues, such as comorbid conditions, may lead to a different final diagnosis
than otherwise would be expected.Symptoms and Indicators In patients who
do not communicate verbally, there are many cues that can lead a psychiatrist
to recognition of psychosis. The following list was compiled from observing
patients with psychosis who were able to communicate verbally. After
observations, patients later explained the psychosis content. This information
is valuable in that the results might be extrapolated as possible indicators in
people who do not use verbal communication.
Patient stares to the side, nods and gestures as though listening to a
conversation others do not hear. It is important to note that some people have
been trained to do this or have learned to do this to occupy themselves
("self-talk"). If the patient seems to be in complete control of this
activity or is using this activity for self-soothing purposes, the presence of
true psychosis is less likely.
Patient seems to be shadow boxing with unseen others (unless, as in above, the
patient is in total control of the activity or doing so for soothing purposes).
Patient brushes unseen material off themselves. Conditions that could produce
paresthesias are more common in individuals with developmental disabilities
than is psychosis and should be considered first.
Patient wears multiple layers of clothing. It is important to note that some
people do this to self-treat sensory integration deficits. In addition, some
people learn this as a coping skill in some congregate facilities, as a way to
keep one's possessions.
Patient covers eyes or ears as though shutting out stimuli, with the caveat
that this can be an expression of anxiety or physical pain.
Patient places unusual wrappings (e.g., feminine hygiene products) around their
ankles, sleeve ends, ears or collars, also keeping in mind this could be an
expression of anxiety or physical pain.
Patient glares with an out-of-context, angry or intensely fearful expression at
strangers or previously liked others.
Patient wraps bandannas or extra scarves around the head and ears when this is
not congruent with the weather or the rest of the person's clothing.
Patient wears costumes that are associated with a false role (e.g., wearing
full firefighter gear when the patient is not a firefighter); caveat: the person
may be expressing a wish rather than a false belief.
Patient inspects food and beverages with new and out-of-context intensity.
Patient grimaces or winces as though smelling or tasting something foul.
Similarly, there are symptoms that are just as important to recognize which are
almost never indications of psychosis. They include the following:
Volitional self-talk.
Vocal tics. Tourette's syndrome and other tic disorders are much more common in
individuals with developmental disabilities than in the general population.
When someone is making nonsensical noises, this possibility should be
considered.
Phenomena that are modeled directly from other people.
Phenomena that the person can start and stop at will.
Phenomena thought to be purely taught by circumstance or program. (Consultation
with a behavior specialist and completion of a functional analysis [this refers
to the process used by modern behaviorists, not a listing of the person's
skills] can make this distinction.)
Displays of aggression, agitation, shouting or self-injury.Epidemiology
ConsiderationsBetween 70% and 85% of people with developmental disabilities
referred for psychiatric consultation have one or more untreated, undertreated
or undiagnosed medical problems influencing their behavior (Ryan and Sunada,
1997; Sundheim et al., 1998). Many of these conditions can produce delirium,
which may include psychosis (Ryan et al., 1998). Therefore, it is essential to
conduct a thorough search for secondary medical conditions that contribute to
or possibly cause the apparent psychosis (Szymanski et al., 1990).Between 60%
and 100% (depending on sample) of individuals with developmental disabilities
have experienced trauma, usually repeated incidents of abuse (Sobsey, 1994).
Since many symptoms that resemble psychosis are actually dissociative
phenomena, careful evaluation for posttraumatic stress disorder and other
sequelae of trauma should be considered. Due the nature of their disabilities,
patients commonly develop habits that could lead to suspicious behaviors. For
instance, some people were given medications hidden in their foods; this may
cause them to inspect food with extreme intensity. Others touch themselves in
unusual ways or look at people with suspicion or anger in relation to flashbacks.
Careful assessment of the rest of the patient's symptoms should assist with the
diagnostic distinctions.Mood disorders with psychotic features are more common
in people with developmental disabilities than are conditions in the
schizophrenia spectrum (Szymanski and Crocker, 1989). Support staff and/or
family members may not be attuned to monitor symptoms such as sleep problems,
appetite problems and other neurovegetative signs of mood disorders; and the
examiner will need to probe very carefully to establish these
criteria.Individuals with pervasive developmental disorders and autism often
have sensory integration deficits that can produce a variety of physical
discomforts. Some people self-manage these discomforts with unusual gestures,
postures or withdrawal. Evaluation of sensory integration status by an
occupational therapist can help avoid misattribution of these symptoms to
psychosis (Sundheim et al., 1998).When updated criteria are used, it appears
that schizophrenia spectrum conditions are as rare in this population as in any
other. Thus, even if the presence of psychosis is established, schizophrenia
may still be the least likely diagnosis. By observing problems with initiation,
gating deficits and affect inconsistent with content, clinicians can clarify
the diagnosis and the long-term treatment plan. Specific clinical questions
might include ascertaining if the person has a hard time getting started in
preferred familiar activities, if the person appears to have more confusion and
psychosis in preferred stimulating situations, or if the person seems to laugh
at things that are frightening or gruesome. Individuals with schizophrenia tend
to have more symptoms of psychosis in situations that are stimulating, even if
it is something the person likes. If the symptoms resembling psychosis occur
more often in low stimulation situations or in association with reminders of
previous trauma, dissociation may be the more accurate diagnosis (Ryan, 1994a).
Olfactory or gustatory hallucinations are much more common in certain forms of
epilepsy and posttraumatic stress disorder than in schizophrenia spectrum
conditions (Neppe and Tucker, 1988; Ryan, 1994b). One man, for example, was
known to repeatedly wrinkle his nose and look at others as though smelling
flatus. It was eventually discovered that he had complex partial seizures with
a temporal lobe focus and ictal violence. Treatment of the epilepsy produced a
remission of ictal violence as well as a remission of this frequently seen
gesture.Certain physical gestures can be easily mistaken for psychosis. A
person who bats out with their hands as though something were there might be
experiencing visual hallucinations; in my clinical experience, however, the
last several times this was a symptom, the cause turned out to be uncorrected
myopia. Similarly, individuals who wave fingers in front of their eyes or bang
their heads are more likely to have headaches or depression than psychosis.Of
course, it is reasonable to attempt to interview all individuals, even those who
do not use speech. Many understand more than they can express and can give very
helpful answers via gestures, nods, drawings and non-speech vocalizations
(Ryan, 2001; Stavrakaki and Klein, 1986; Trumble, 1993). ConclusionGathering
observational data from the patient and from those who know the patient very
well (i.e., family, caregivers and so on), as well as from videotaping and
spending unstructured time with the patient, is essential to correctly
identifying psychosis in nonverbal patients with developmental disabilities
(Ryan, 2001; Szymanski, 1977). All observational data should be augmented with
a complete database regarding family history and all physical signs and
symptoms. The environmental context of a symptom of possible psychosis is
essential in understanding its significance and meaning, if any. The time spent
in these initial assessments is richly repaid in better quality of life and
clinical outcomes for the patient. If, despite all attempts to gather complete
data, the clinical outcome is not favorable, restarting the process with
particular attention to unstructured observation may be helpful. Guides and
other reading material (Table) are also helpful to the psychiatrist encountering such
patients.Dr. Ryan works full time with people with developmental disabilities,
is clinical assistant professor of psychiatry at University of Colorado Health
Sciences Center, and directs a non-profit research and education foundation. ReferencesAman
MG (1991), Assessing psychopathology and behavior problems in persons with
mental retardation: a review of available instruments. Publication No.
(ADM)91-1712. Rockville, Md.: U.S. Department of Health and Human Services,
Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration,
National Institute of Mental Health.Neppe VM, Tucker GJ (1988), Modern
perspectives on epilepsy in relation to psychiatry: behavioral disturbances of
epilepsy. Hosp Community Psychiatry 39(4):389-396.Ryan R (1994a), Posttraumatic
stress disorder in persons with developmental disabilities. Community Ment
Health J 30(1):45-54.Ryan R, Sunada K (1997), Medical evaluation of persons
with mental retardation referred for psychiatric assessment. Gen Hosp
Psychiatry 19(4):274-280.Ryan RM (1994b), Recognition of psychosis in persons
who do not use spoken communication. In: Schizophrenia: Exploring the Spectrum
of Psychosis, Ancill RJ, Holliday S, Higenbottam J, eds. New York: Wiley
Press.Ryan RM (2001), Handbook of Mental Health Care for Persons with
Developmental Disabilities. Quebec: Diverse City Press Inc.Ryan RM, Sundheim
STPV, Voeller KKS (1998), Medical diseases. In: Textbook of Pediatric
Neuropsychiatry, Coffey CE, Brumback RA, eds. Washington, D.C.: American
Psychiatric Press, pp1223-1274.Sobsey D (1994), Violence and Abuse in the Lives
of People with Disabilities: The End of Silent Acceptance? Baltimore: P.H.
Brookes Publishing Co.Stavrakaki C, Klein J (1986), Psychotherapies with the
mentally retarded. Psychiatr Clin North Am 9(4):733-743.Sundheim STPV, Ryan RM,
Voeller KKS (1998), Mental retardation. In: Textbook of Pediatric
Neuropsychiatry, Coffey CE, Brumback RA, eds. Washington, D.C.: American
Psychiatric Press, pp649-690.Szymanski L, Madow L, Mallory G et al. (1990),
Report of the task force on psychiatric services to adult mentally retarded and
developmentally disabled persons. Washington, D.C.: American Psychiatric
Association.Szymanski LS (1977), Psychiatric diagnostic evaluation of mentally
retarded individuals. J Am Acad Child Psychiatry 16(1):67-87.Szymanski LS,
Crocker AC (1989), Mental retardation. In: Comprehensive Textbook of
Psychiatry, vol. 2, 5th ed., Kaplan HI, Sadock BJ, eds. Baltimore: Williams
& Wilkins.Trumble S (1993), Communicating with people who have intellectual
disabilities. Aust Fam Physician 22(6):1081-1082.
http://www.mhsource.com/pt/p011251.html
******************************
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