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By H. Tjalf. New England College of Optometry.
Alternative transmission routes for malarial plasmodia include diaplacen- tal infection generic 60pills rumalaya amex medications j tube, blood transfusions (plasmodia survive in stored blood for five days, rarely longer), and contaminated needles used by drug addicts. Etiological confirmation of a clinical diagnosis is obtained by de- tecting malarial parasites in the blood (Fig. Capillary blood is sampled before chemotherapy is started, if possible before the onset of fever, and ex- amined microscopically in both thick and thin blood smears following Giem- sa staining (p. Stages of , , and can be found in blood five to eight days after the infection at the earliest, not until after 13–16 days. Rapid tests (ParaSight, MalaQuick) have also been available for some years to diagnose infections. Detection of specific antibodies in the serum of persons infected with plasmodia for the first time is not possible until six to 10 days after inocula- tion (Table 11. In such cases, a serological antibody assay is not a suitable tool to confirm a diagnosis in an acute attack of malaria, although this method does provide valuable help in confirming older infections and screening out blood donors infected with plasmodia. Therapy and intensive clinical monitoring must therefore begin immediately, especially in acute malignant tertian malaria (malaria tropica) (medical emergency! The best that can be offered here by way of a description of the highly complex field of malaria treatment is a brief sketch of the main principles involved. Differential diagnosis of the eggs of important helminths (trematodes, cestodes, and nematodes) and of the larvae of. The parasite has two elongated grooves (bothria) on its head, it is 2–15m long with numerous (up to 4000) proglottids (Fig. The life cycle includes copepods as pri- mary and freshwater fish as secondary intermediate hosts. Humans acquire the infectionwhen eating raw or undercooked fish containing infective stages (plerocercoids) of the tapeworm. The course of a infection is often devoid of clinical symptoms, with only mild gastrointestinal distress in some cases. Anemia and other symptoms due to vitamin B12 uptake by the parasite is observed in about 2% of tapeworm carriers. Diagnosis is made by detection of eggs in stool, sometimes proglottids are excreted. The plerocercoids can be killed by boiling or deep-freezing (24 hours at –18 C or 72 hours at –10 C). The nematodes (: thread) are threadlike, nonsegmented para- sites, a few mm to 1m in length, with separated sexes. The males are usually smaller than the females and are equipped with copulatory organs that often show features specific to each species. Development from the egg includes four larval stages and four moltings before the adult stage is reached. Careful diagnostic examinations are therefore necessary if a infection is suspected. The adult ascarids living in the small intestine ( : worm) are 15–40cm in length, about as thick as a pencil and of a yellow- ish pink color (Fig. The sexually mature females produce as many as 200 000 eggs per day, which are shed with feces in the unembryonated state. The round-to-oval eggs are about 60 45 m in size, have a thick, brownish shell and an uneven surface (Fig. At optimum temperatures of 20–25 C with sufficient moisture and oxygen, an infective larva in the egg develops within about three to six weeks. Human infections result from peroral ingestion of eggs containing larvae, which hatch in the upper small intestine and penetrate into the veins of the intestinal wall. Via tracheopharyngeal migration they finally reach the digestive tract, where they further differentiate into adults in the small intestine. Female from the small intestine; first-stage larva (L1) shed in stool; L2 larva; infective L3 larva; development of L1 larva to adult stages including four moltings (); free-living male (not host-bound); free- living female; egg of free-living generation; larva hatched from egg, develops into infective larva including two moltings. Duration of life cycle about three weeks, lifespan on host usually four to five weeks, rarely as long as two months; can survive without a host at 10–20C for about one week and at 0–10C for approximately 10 days. Bite reactions on the body, espe- cially around the underwear, are indicative of body louse infestation. Serology; worm eggs in stool (larvae) Serology (larvae) Serology (specific IgE) (worm eggs in stool) spp. Empyema Microscopy and culture from pleural pus specimen Numerous other bacteria are potential pathogens Pulmonary abscess Usually endogenous Microscopy and culture from Necrotizing pneumonia infections with Gram- transtracheal or bronchial negative/Gram-positive aspirate, bronchoalveolar mixed anaerobic flora lavage or lung biopsy.
This implies that holding both positive and negative attitudes to a food makes it less likely that the overall attitude will be translated into an intention to eat it 60 pills rumalaya amex medicine 0636. Predicting behaviour: exploring the intention–behaviour gap Sutton (1998a) argued that although structured models are ineffective at predict- ing behavioural intentions they are even less effective at predicting actual behaviour. In fact, he suggested that studies using these models only predict 19–38 per cent of the variance in behaviour. Some of this failure to predict behaviour may be due to the behaviour being beyond the control of the individual concerned. For example, ‘I intend to study at university’ may not be translated into ‘I am studying at university’ due to economic or educational factors. Further, ‘I intend to eat healthily’ may not be trans- lated into ‘I am eating healthily’ due to the absence of healthy food. In such instances, the correlation between intentions and behaviour would be zero. However, for most behaviours the correlation between intentions and behaviour is not zero but small, suggesting that the individual does have some control over the behaviour. Psychologists have addressed the problem of predicting actual behaviour in three ways: (1) the con- cept of behavioural intentions has been expanded; (2) past behaviour has been used as a direct predictor of behaviour; and (3) variables that bridge the intention–behaviour gap have been studied. Expanding behavioural intentions Much of the research that uses models to predict health behaviours focuses on behavioural intentions as the best predictor of actual behaviour. However, recent researchers have called for additional variables to be added which expand behavioural intentions. They suggested that such self-predictions are more likely to reflect the individual’s consideration of those factors that may help or hinder the behaviour itself. To date, some research supports the usefulness of this new variable (Sheppard et al. Paisley and Sparks (1998) argued that it is the perception by an individual that they need to change their behaviour which is critical. For example, an intention ‘I intend to stop smoking’ may be less influential than a perceived need to stop smoking ‘I need to stop smoking’. They examined the role of perceived need in predicting expectations of reducing dietary fat and argued for the use of this variable in future research. Therefore, by expanding behavioural intentions to include self-predictions, behavioural willingness and/or perceived need it is argued that the models will be become better predictors of actual behaviour. The role of past behaviour Most research assumes cognitions predict behavioural intentions, which in turn predict behaviour. This is in line with the shift from ‘I think, therefore I intend to do, therefore I do’. It is possible, however, that behaviour is not predicted by cognitions but by behaviour. From this perspective, individuals are more likely to eat healthily tomorrow if they ate healthily today. They are also more likely to go to the doctor for a cervical smear if they have done so in the past. In terms of past behaviour, research suggests that it predicts behaviours such as cycle helmet use (Quine et al. In addition, past behaviour may itself predict cognitions that then predict behaviour (Gerrard et al. In terms of habit, research indicates a role in explaining condom use (Trafimow 2000) and that habit reduces people’s use of information (Aarts et al. In particular, some research has highlighted the role of plans for action, health goals commitment and trying as a means to tap into the kinds of cognitions that may be responsible for the translation of intentions into behaviour (Bagozzi and Warshaw 1990; Schwarzer 1992; Bagozzi 1993; Luszczynska and Schwarzer 2003). Most research, however, has focused on Gollwitzer’s (1993) notion of implementation intentions. According to Gollwitzer, carrying out an intention involves the development of specific plans as to what an individual will do given a specific set of environmental factors. Therefore, implementation intentions describe the ‘what’ and the ‘when’ of a particular behaviour.
Although her re- sults seemed to support what she later would term Rogers defined the unitary human being as “[a]n “health as expanding consciousness order rumalaya 60 pills on line symptoms women heart attack,” at that time irreducible, indivisible, pandimensional energy she felt they did little to inform or shape nursing field identified by pattern and manifesting charac- practice (Newman, 1997a). Finally, Rogers saw the life Introducing the Theory process as showing increasing complexity. This assumption, along with the work of Itzhak Newman’s theory is a composite of her early influ- Bentov (1978), which viewed life as a process of ex- ences and life and practice experiences. Newman’s Theory of Health as Expanding Consciousness and Its Applications 219 in New York. In her address each client situation, (Newman, 1978) and in a written overview of the • the sequential configurations of pattern evolv- address (Newman, 1979), Newman outlined the ing over time, basic assumptions that were integral to her theory. They defined the focus of the Newman’s presentation drew thunderous ap- nursing discipline to be caring in the human health plause as she ended with “[t]he responsibility of the experience, which they saw as the common um- brella under which three distinct paradigmatic per- spectives fell: the particulate-deterministic, the “[t]he responsibility of the nurse is not to interactive-integrative, and the unitary-transfor- make people well, or to prevent their get- mative (with the first word indicating the nature of ting sick, but to assist people to recognize reality and the second word indicating the nature the power that is within them to move to of change in each paradigm). Relationships getting sick, but to assist people to recognize the between entities are seen as orderly, predictable, power that is within them to move to higher levels linear, and causal (i. In this perspective, Although Margaret Newman never set out health is dichotomized with clearly defined charac- to become a nursing theorist, in that 1978 presen- teristics that are either healthy or unhealthy, and tation in New York City she articulated a theory change occurs in a manner that is predictable and that resonated with what was meaningful in the causal in nature. Nurses wanted to go beyond combating stems from the particulate-deterministic, views re- diseases; they wanted to accompany their patients ality as multidimensional and contextual. Multiple in the process of discovering meaning and antecedents and probabilistic relationships are be- wholeness in their lives. Relationships may be reciprocal, and sub- was to focus on how to test the theory with nursing jective data are seen as legitimate. It is identified by ness and is able to sense how physical signs, emo- pattern and by interaction with the larger whole” tional conveyances, spiritual insights, physical (Newman, Sime, & Corcoran-Perry, 1991, p. Newman, Sime, and Corcoran-Perry (1991) Knowledge is arrived at through pattern recogni- concluded that the knowledge generated by the tion and reflects both the phenomenon viewed and particulate-deterministic paradigm and the inter- the viewer. In a later work, Newman (1997a) larger unitary field that combines person, family, asserted that knowledge emanating from the uni- and community all at once. A nurse operating out tary-transformative paradigm is the knowledge of of the unitary-transformative paradigm does not the discipline and that the focus, philosophy, and think of mind, body, spirit, and emotion as separate theory of the discipline must be consistent with entities, but rather sees them as an undivided each other and therefore cannot flow out of differ- whole. Newman states: Newman’s theory (1979, 1990, 1994a, 1997a, The paradigm of the discipline is becoming clear. The nurse and client things to attending to the meaning of the whole, from form a mutual partnership to attend to the pattern hierarchical one-way intervention to mutual process of meaningful relationships and experiences in the partnering. In this way, a patient who has had a of health that focuses on power, manipulation, heart attack can understand the experience of the and control and move to one of reflective, compas- heart attack in the context of all that is meaningful sionate consciousness. It reveals a world in his or her life, and through the insight gained, that is moving, evolving, transforming—a process. The old paradigm pro- practice and conduct research out of a unitary- poses methods that are analogous to trying to ap- participatory paradigm, which sees the process of preciate a loaf of warm bread by analyzing flour, the nursing partnership as integral to the evolving water, salt, yeast, and oil. No matter how much we definition of health for the patient (Litchfield, come to know these ingredients separately, we will 1993, 1999; Newman, 1997a) and is synchro- not know the texture, smell, taste, and essence of nous with participatory philosophical thought the loaf of bread that has just come out of the oven. For example, the smell of the loaf of bread provides one insight Essential to Margaret Newman’s theory is the belief into its nature, the texture provides another, and so that each person exhibits a distinct pattern, which on. Newman’s Theory of Health as Expanding Consciousness and Its Applications 221 consciousness. To explain this phenomenon, Each person exhibits a distinct pattern, Newman (1994a, 1997b) draws on the work of Ilya which is constantly unfolding and evolving Prigogine (1976), whose theory of Dissipative as the person interacts with the environ- Structures asserts that a system fluctuates in an or- ment. Pattern is information that depicts derly manner until some disruption occurs, and the the whole of a person’s relationship with system moves in a seemingly random, chaotic, dis- the environment. Nurses see this all the time—the patient mation that depicts the whole of a person’s rela- who is lost to his work and has no time for his fam- tionship with the environment and gives an ily or himself, and then suddenly has a heart attack, understanding of the meaning of the relationships an experience that leaves him open to reflecting on all at once (Endo, 1998; Newman, 1994a). Insights gained a manifestation of consciousness, which Newman through this reflection give rise to transformation (1994a) defines as the informational capacity of the of his life pattern, which becomes more creative, re- system to interact with its environment. Nurses also see this in To describe the nature of pattern, Newman people diagnosed with a terminal illness that causes draws on the work of David Bohm (1980) who said them to reevaluate what is really important, attend that anything explicate (that which we can hear, see, to it, and then to state that for the first time they feel taste, smell, touch) is a manifestation of the impli- as though they are really living.
Further advice can always be obtained by ringing one of the national poisons information ser- vices buy cheap rumalaya 60 pills on line medicine ubrania. The electrolyte, renal and liver function tests and the clotting studies should be monitored carefully over the first few days, and referral to a liver unit considered if there is marked liver dysfunction. Patients with fulminant hepatic failure are considered for urgent liver transplantation. The other areas that need to be addressed in this case are the mental state and the safety and care of the son and any other children. She should be seen by a psychiatrist or other appropriately trained health worker. The question of any possible risk to the baby should be evaluated before she returns home. On direct questioning she states that she has lost 8 kg in weight over the past year although she says her appetite is good. This is a disorder usually of teenagers or young adults char- acterized by severe weight loss, a disorder of body image (the patient perceiving themself as being fat despite being objectively thin) and amenorrhoea (or, in men loss of libido or potency). Often sufferers from this condition work in a profession where personal image is very important, e. Some patients exhibit the bulimic behaviour of recurrent bouts of overeating and self-induced vomiting. The skin is dry with growth of lanugo hair over the neck, cheeks and limbs as in this woman. Severe physical complications include proximal myopathy, cardiomyopathy and peripheral neuropathy. A number of interrelated mechanisms cause the metabolic alkalosis in this patient. The vom- iting causes a net loss of hydrogen and chloride ions, causing alkalosis and hypochloraemia. The loss of fluid by vomiting leads to a contracted plasma volume with consequent second- ary hyperaldosteronism to conserve sodium and water, but with renal loss of potassium, due to its secretion in preference to sodium and the fact that fewer hydrogen ions are available for secretion by the renal tubules. These events combine to give the typical picture of an alkalosis with low chloride and raised bicarbonate in the blood, and urine which contains excess potassium and very little chloride. This patient should be referred to a unit with a special interest in eating disorders. Other serious physical illnesses should be excluded with the appropriate investigations. Often such patients are admitted for several weeks in an attempt to make them gain weight. Supportive psychotherapy tackles the patient’s disordered perception of their body image. This developed suddenly a week previously after carrying a heavy suitcase at the airport. She has had increasing problems with back pain over the past 10 years, and her family have commented on how stooped her posture has become. She takes courses of oral corticosteroids, and use steroid inhalers on a regular basis. She has a moon-face, abdominal striae and a number of bruises on her arms and thighs. The loss of height is typical, and is usually noted more by others than the patient. This can occur spontaneously or in association with a recognized stress such as carrying a heavy load. Examination confirms loss of trunk height, thoracic kyphosis and proxim- ity of the ribs to the iliac crest. The differential diagnoses of osteoporosis • Multiple myeloma • Metastatic carcinoma, particularly from the prostate, breast, bronchus, thyroid and kidney • Osteomalacia • Hyperparathyroidism • Steroid therapy or Cushing’s syndrome This patient has several risk factors for osteoporosis. Thirdly she has been on oral and inhaled corticosteroids for her asthma for years. She has no clinical evidence of thyrotoxicosis or hypopituitarism which can cause osteoporosis. This woman should have blood tests to exclude myeloma, cancer and metabolic bone dis- ease.
Carbon dioxide carriage and some haemoglobinopathies (methaemoglobin order 60pills rumalaya free shipping medications diabetes, sickle cell, thalassaemia) are also discussed. The fraction of inspired oxygen (FiO2) should be expressed as a decimal (or a fraction). Thus Oxygen carriage Oxygen is carried by blood in two ways: ■ plasma (3 per cent) ■ haemoglobin (97 per cent) At normal (sea-level) atmospheric pressure 0. As cardiac output would need to be about 100 litres per minute to meet metabolic demands (Prencipe & Brenna, undated), oxygen Gas carriage 155 carriage by plasma is normally insufficient to maintain life. Erythrocyte production takes eight days, cells remaining functional for approximately 120 days, with 1 per cent of erythrocytes being replaced each day. Renal or bone marrow disease reduces erythrocyte production, resulting in hypoplastic anaemia. Each haemoglobin molecule contains two pairs of polypeptides, making haemoglobin a large molecule (weighing about 64,450 Da (Ganong 1995)) and so above capillary permeability. Haemoglobin is therefore not normally lost into interstitial fluid (oedema) or urine. An average 70 kg adult has about 900 grams of circulating haemoglobin, giving ‘normal’ levels of 14–18 g/dl for men and 12–16 g/dl for women (Rowswell 1997). Lower concentrations decrease viscosity, so aid perfusion: 10 g/dl being preferred with critically ill patients. Macrophages metabolise old erythrocytes, releasing iron (for further haemoglobin synthesis) and waste (excreted in bile). Polypeptides of normal adult haemoglobin (HbA) consist of two alpha and two beta chains:. The slight biochemical differences between alpha and beta chains are not significant for clinical nursing, but abnormalities of either chain can cause pathologies. Each erythrocyte contains approximately 640 million haemoglobin molecules (Hoffbrand & Pettit 1993). Adult haemoglobin normally replaces fetal haemoglobin soon after birth, although the latter can (abnormally) persist throughout life, predisposing patients to tissue hypoxia. Haemoglobin levels of 10 g/dl with an average 5-litre circulating volume give a total body haemoglobin of. If all four limbs of the molecule carry oxygen, the haemoglobin is described as fully (100 per cent) saturated. Saturation of total haemoglobin (not single molecules) can be measured through oximetry (e. While haemoglobin is an efficient transport mechanism for oxygen, usually only 20– 25 per cent of available oxygen unloads, leaving normal venous saturations (SvO2) of 70– 75 per cent. This large venous reserve can provide oxygen without any increase in respiration rate or cardiac output so that, while SaO2 indicates oxygen availability, the SaO2-SvO2 gradient indicates tissue uptake (consumption) of oxygen, measured through cardiac output studies (see below). Prussic acid is found in cyanide, one of the degradation products of sodium nitroprusside. Partial pressure of gases Air contains approximately 21 per cent oxygen and 79 per cent nitrogen, with negligible amounts of other gases (carbon dioxide is 0. Thus the partial pressure of each gas is determined by the difference between total barometric pressure and water pressure vapour percentage concentration of gas, which is then divided in proportion to percentage concentration of gases (see Table 18. Alveolar gas tensions are altered by rebreathing ‘dead space’ gas, relatively rich in carbon dioxide and poor in oxygen. Physiological adult dead space is about 150 ml; additional pathological dead space exists when alveoli are not perfused. With artificial ventilation, dead space begins at the inspiratory limb (‘Y’ connector) of ventilator tubing. Cellular respiration The purpose of respiratory function is to supply tissue cells with sufficient oxygen to enable mitochondrial activity and remove carbon dioxide (a waste product of metabolism). Mitochondria are the powerhouses of the cell, so that their failure leads to cellular damage and eventual cell death. Currently, it is not practical to monitor mitochondrial respiration, and cruder parameters (e. However, the end of respiratory function should be remembered when assessing intermediate parameters.
Infection by cytopathic pathogens can only be controlled if pathogenic proliferation is slow and the pathogen remains localized; otherwise the outcome is usually fatal buy cheap rumalaya 60 pills online symptoms 0f food poisoning. In the case of noncytopathic pathogens, the cytotoxic T-cell response is the critical parameter. The T-cell response can be halted by pathogens which proliferate rapidly and spread widely due to the deletion of responding Tcells. For pathogens which exhibit moderate rates of proliferation and spread, the T-cell response may cause extensive immunopathological damage, and thus reduce the proportion of surviving hosts, some of which will controll virus, some not. A weakened immune defense system may not progress beyond an unfavorable virus-host balance, even when confronted with a static or slowly replicating patho- gen which represents an initially favorable balance. Although de- tails of the process are still sketchy, IgE-dependent basophil and eosinophil defense mechanisms have been described for model schistosomal infections. Usage subject to terms and conditions of license 102 2 Basic Principles of Immunology & Avoidance strategies. Infectious agents have developed a variety of stra- tegies by which they can sometimes succeed in circumventing or escaping immune responses, often by inhibiting cytokine action. Short-lived IgM responses can control bacteria in the blood effectively, but are usually insufficient in the controlof toxins. In such cases, immunoglobulinsof the IgGclass are more efficient, as a result of their longer half-life and greater facility for diffusing into tissues. Avoidance Mechanisms of Pathogens (with examples) Influence on the complement system. Some pathogens prevent complement fac- tors from binding to their surfaces: & Prevention of C4b binding; herpes virus, smallpox virus. Viruses can avoid confrontation with the immune defenses by restricting their location to peripheral cells and or- gans located outside of lymphoid tissues: & Papilloma viruses; infect keratinocytes. Infection agents can avoid immune defenses by mutating or reducing their expression of T- or B-cell epitopes. Usage subject to terms and conditions of license Immune Defenses against Infection and Tumor Immunity 103 Continued: Avoidance Mechanisms of Pathogens (with examples) Influence on lymphocytes and immunosuppression. Immune Protection and Immunopathology Whether the consequences of an immune response are protective or harmful depends on the balance between infectious spread and the strength of the ensuing immune response. As for most biological systems, the immune de- fense system is optimized to succeed in 50–90% of cases, not for 100% of cases. For example, immune destruction of virus-infested host cells during the eclipse phase of a virus infection represents a potent means of preventing virus replication (Fig. If a noncytopathic virus is not brought under im- mediate control, the primary illness is not severe—however, the delayed cy- totoxic response may then lead to the destruction of very large numbers of infected host cells and thus exacerbate disease (Tables 2. Since an infection with noncytopathic viruses is not in itself life-threatening to the Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license 104 2 Basic Principles of Immunology Table 2. Auto- “Healthy” or unknown infections, immunity occult carrier viruses, bacteria, (although infec- and endogenous tious agent is retroviruses unknown) Clinical None Chronic Variable disease symptoms disease symptoms, some- times delayed or asymptomatic Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license Immune Defenses against Infection and Tumor Immunity 105 Table 2. A similar situation is also observed for the cellular immune response against facultative intracellular tuberculosis and leprosy bacilli which themselves have relatively low levels of pathogenicity (Table 2. A healthy immune system will normally bring such infectious agents under control efficiently, and the immunological cell and tissue damage (which oc- curs in parallel with the elimination of the pathogen) will be minimal, en- suring that there is little by wayof pathological or clinical consequence. How- ever, should the immune system allow these agents to spread further, the result will be a chronic immunopathological response and resultant tissue destruction—as seen during hepatitis B as chronic or acute aggressive hepatitis and in leprosy as the tuberculoid form. Should a rapidly spreading infection result in exhaustion of the T cell response, or should an insufficient level of immunity be generated, the infected host will become a carrier. This carrier state, which only occurs during infections characterized by an absent or low- level of cytopathology, is convincingly demonstrated in hepatitis B carriers and sufferers of lepromatous leprosy. Because the im- muneresponse also acts toinhibit virus proliferation, the process of cellulardestruc- tion is generally a gradual process.
Mania creates enormous turmoil in the lives of its Research has correlated birth order with such as- victims generic rumalaya 60pills mastercard medicine river animal hospital, many of whom turn to drugs or alcohol as a way pects of life as temperament and behavior. For example, of coping with the anxiety generated by their condi- first-born children, when compared to their siblings, tend tion—61 percent of persons with bipolar disorder have to score slightly higher on intelligence tests and to attain substance abuse or dependency problems. Some psycholo- percent of those who fail to receive adequate treatment gists believe that birth order is a significant factor in the for bipolar disorder commit suicide. As part dividuals commonly suffer from it for as long as seven to of his view that patients need to be understood in the con- ten years without being diagnosed or treated. Lithium, a child’s position in the family is associated with certain which stabilizes the brain chemicals involved in mood problems that are responded to in similar ways by other swings, is used to treat both the mania and depression of children in the same birth position. This drug, which is taken by millions of was not the numerical birth position itself that mattered people throughout the world, halts symptoms of mania in but rather the situation that tended to accompany that po- 70 percent of those who take it, usually working within sition, and the child’s reaction to it. Antipsy- first-born children, when compared to their siblings, tend chotic drugs or benzodiazepines (tranquilizers) may ini- to have a greater chance of developing feelings of inferi- tially be needed to treat cases of full-blown mania until ority as their focal position in the family structure is al- lithium can take effect. Later-born children, on the their blood levels, as well as kidney and thyroid func- other hand, tend to have stronger social skills, having had tions, monitored regularly, as there is a relatively narrow to deal with siblings throughout their lives, as opposed to gap between toxic and therapeutic levels of the drug. Later-borns, having had to compromise more after manic-depressive symptoms subside. All chil- child feel better by cuddling him or giving him special at- dren become jealous of the love and attention that sib- tention, including a small present to offset the gifts re- lings receive from parents and other adults. The older child’s self-esteem can be baby is brought home, older children feel betrayed by bolstered by involving him in the care of newborn in their parents and become angry, directing their anger first modest ways, such as helping out when the baby is being toward the parents and later toward the intruder who is diapered or dressed, or helping push the carriage. Jealousy, resentment, and compe- older child should be made to feel proud of the attain- tition are most intense between siblings spaced less than ments and responsibilities that go along with his more three years apart. Although a certain amount of sibling ri- advanced age—things the new baby can’t do yet because valry is unavoidable, there are measures that parents can he is too young. Another way to make older children feel take to reduce its severity and its potential effects on their loved and appreciated is to set aside some “quality time” children. It is also important for parents to avoid overtly comparing An older child should be prepared for a new addition their children to each other, and every effort should be to the family by having the situation explained and being made to avoid favoritism. The child’s regu- In general, the most stressful aspect of sibling rivalry lar routine should be disturbed as little as possible; it is is fighting. If there is to not to take sides but rather to insist that the children work be a new babysitter or other caretaker unknown to the out disagreements themselves, calling for a temporary child, it is helpful for them to meet at least once in ad- “time out” for feelings to cool down, if necessary. If sibling visits are allowed, the child should be form of parental involvement in squabbling by siblings taken to visit the mother and new baby in the hospital. Over-in- Once the new baby is home, it is normal for an older sistence that siblings share can also be harmful: to retain child to feel hurt and resentful at seeing the attention lav- a sense of individuality, children need some boundaries ished on the newcomer by parents, other relatives, and fam- from their siblings in terms of possessions, territory, and ily friends. Furthermore, it is especially difficult for very the experience to cause disturbances in eating or sleeping. Some children regress developmentally, temporarily losing Parents should take time to praise cooperation and such attainments as weaning, bowel and bladder control, or sharing between siblings as a means of positive reinforce- clear speech, in an attempt to regain lost parental attention ment. The fact that siblings quarrel with each other does by becoming babies again themselves. The security of family often makes children feel the arrival of a younger sibling. When friends or relatives free to express feelings and impulses they are unable to visit to see the new baby, parents can make the older in other settings. It has also been posited that birth order influences one’s Separate studies have found high academic achievement choice of a marriage partner. The “duplication hypothe- levels among first-borns in both urban ghettoes in the sis” advanced by Walter Toman (1976) states that people United States and at British universities. First-born chil- seek to duplicate their sibling relationships in marriage, a dren are generally responsible, assertive, and task-orient- duplication that includes birth order. They are more frequently mentioned in Who’s Who publica- More specific research on the effects of birth order tions than individuals in any other birth position and are has generally focused on five ordinal birth positions: overrepresented among members of Congress and U. Studies have consistently linked first-born dents are especially vulnerable to stress and tend to seek children and academic achievement. Adler found that there were more born National Merit Scholarship winners was found to first-borns than later-borns among problem children. While most psychoana- ly high level of success in team sports, and both they and lytical psychologists assign a moderate degree of impor- last-borns have been found to be better adjusted emotional- tance to the birth trauma in terms of its effects, some be- ly if from large families.
