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They can be taught to blood pressure medication beginning with h generic verapamil 120 mg overnight delivery state clearly that what is happening is wrong blood pressure chart age 40 generic 80 mg verapamil otc, that it must stop blood pressure lowering herbs purchase verapamil 80 mg visa, and that if it does not stop it will be reported blood pressure of 9060 cheap verapamil 120mg fast delivery. There are some children within the silent majority who have a high social status, a strong sense of social justice and natural asser tiveness. These children can be personally encouraged, and can be highly successful in intervening, to stop bullying. Their high social status may also encourage other children to express their disapproval. I suggest that part of the children’s code on bullying should include commendations for a positive intervention by a bystander, but that other children who were present but did not try to intervene should experience some consequences for their inaction, which has indirectly enabled the bullying to occur. There needs to be group responsibility for acts of omission rather than commission: in other words, consequences for what they did not do. A guardian the teacher can encourage a ‘buddy’ or guardian system, with the guardian recruited from the group of high social status children with a social conscience. His or her role is to monitor the circumstances of the child with Asperger’s syndrome, to report any incident confidentially, to encourage the target to report the incident, and to state publicly that the situation is not funny and that the teasing or bullying must stop. Another valuable characteristic of the guardian is to repair the emotional and self-esteem damage inflicted on the child or adolescent with Asperger’s syndrome. An adult may be sympathetic and provide reassurance but the restorative value of a support ive comment from a popular peer can be a very effective antidote. The monitor or guardian should be a socially aware child who is easily able to distinguish between friendly and non-friendly acts, and respond accordingly. The guardian can also rescue the child with Asperger’s syndrome in situations that adults find difficult to monitor. Liane Holliday Willey describes in her autobiography an example of the benefits of her guardian, Craig. Truth be known, they may not have, had it not been for a very good friend of mine named Craig. With him by my side, I was given an instant elevated status among our group and beyond. He had been my friend almost forever and over the years he had become almost like a guardian to me. In subtle and overt ways, he would show his support for me by saving me a seat at lunch, walking me to class, or picking me up to take me to a party. If genuine friends or relatives provide such support, their guardianship should be recognized, commended and encouraged. A child with Asperger’s syndrome may try to find a socially isolated sanctuary but this can be one of the most vulnerable situations. Luke Jackson, a teenager who has Asperger’s syndrome, offers some advice: One day things just got too much to bear. I had tried to hide in the changing rooms away from my tormentors – I wish I had written my book then as I would have realized that hiding away is the worst thing to do. These two lads (low-lifes) found me and began toying with me in much the same way as a cat plays with a mouse. I know it sounds strange but when you think you are hiding you are most likely to be found and bullied. The best thing to do is stay with your friend if you have one, or at least a place where there are lots of people around. Other options can be the pro vision of activities in a supervised classroom during break times, such as a chess club; or an opportunity for like-minded individuals to meet as a group in the playground. There are conventional recommendations regarding what to do when being the target that can actually make the situation worse. Donna Williams wrote to me regarding the bullying she experienced as a child, explain ing how her lack of or delay in response, especially to pain, led other children to think ‘it doesn’t mattershe can’t feel it’. The general advice is for such children to try to stay calm, maintain their self-esteem, and respond in an assertive and constructive way. Staying calm and maintaining self-esteem is difficult for children with Asperger’s syndrome, but self-talk strategies can be used to maintain self-control. Children who are a target need to know and remember that they are not at fault, they do not deserve the comments or actions, and the people who need to change their behaviour are those who are committing the bullying acts. Gray (2004a) recommends the creation of one simple spoken response that is true and used consistently. This would in any case be difficult for children with Asperger’s syndrome, who are known for their reluctance to lie. Children with Asperger’s syndrome would have considerable difficulty creating humour in such a situation. If the target child is unsure whether the actions of the other person are friendly or not, a reply could be, ‘Are you teasing me to be friendly or not friendly The child can then try to leave the situation, moving towards an adult or a safe group of children. If the bullying occurs in class, then the teacher can allow the child who is the target to move to another part of the classroom, perhaps without having to ask permission first. The child with Asperger’s syndrome will especially need guidance when he or she transfers to middle school or high school where the predatory students are at their peak in terms of teasing and bullying. Nita Jackson, in her autobiography, has very wise words of advice: Having Asperger’s syndrome does not make me less human, less emotional, but simply more vulnerable. So I conclude that other Asperger teenagers like myself should always be forewarned of the problems they can and will encounter with mainstreamers. The first stage is to explore with the child why someone would engage in a bullying act. The thoughts and motivations of others are not obvious for children with Asperger’s syndrome, owing to inherent difficulties with Theory of Mind abilities. The child can be very confused as to why someone would be so unkind, why he or she became the target, and what he or she is supposed to think and do. I recommend two strategies developed by Carol Gray (1998), namely Comic Strip Conversations, which can be used to discover and explain the thoughts and feelings of each participant in the incident, and Social Stories™, to determine what to do if similar circumstances occur again. Comic Strip Conversations Comic Strip Conversations involve drawing an event or sequence of events in story board form, with stick figures to represent each person involved, and speech and thought bubbles to represent each participant’s words and thoughts. The child and teacher use an assortment of fibre-tipped coloured pens, with each colour representing an emotion. As he or she fills in the speech or thought bubbles, the child’s choice of colour indicates his or her perception of the emotion conveyed or intended. This can clarify the child’s interpretation of events and the rationale for his or her response. This activity can also help the child to identify and rectify any misperception, and to deter mine how alternative responses will affect each participant’s thoughts and feelings. When new responses have been identified, the child will benefit by being able to rehearse those responses using role-playing activities, and by being encouraged to report back when a particular strategy has proved effective. The child with Asperger’s syndrome can enjoy creating a ‘boasting book’ of the new successful responses, espe cially if the successful management of the event achieves a commendation and a suitable reward. Resources the child can read age-appropriate fiction in which the central character experiences bullying and responds in ways intended to serve as a model for the young reader. I rec ommend careful selection of any reading material relevant to bullying, as some of the strategies in the text may not be consistent with conventional wisdom on preventing bullying, or are not appropriate for children with Asperger’s syndrome. There are many programs on the prevention of bullying in schools for typical children, and some of the activities in these programs can be used with children with Asperger’s syndrome (Rigby 1996). Parents of children with Asperger’s syndrome will be requesting that schools implement these new programs. Parents are essential to the team approach to reducing bullying, and they will need to be aware of the policies and relevant programs at their child’s school, and be active partici pants in encouraging specific responses. Parents also have a role in encouraging the child to have the confidence and ability to disclose his or her experiences as a target and to talk to a friend, teacher, parent or counsellor. A parent may consider enrolling the child in a martial arts course to increase skills in self-protection as a deterrent to acts of bullying. However, I would recommend the martial arts course focus on how to remain calm and escape particular holds and actions, rather than to injure the other child. Parents may also need to know that research on typical children has indicated that simply changing school has little effect on reducing the likelihood that a child will be a target of bullying (Olweus 1993). However, parents may transfer the child to a different school that has a renowned intervention program to reduce the incidence and effects of teasing and bullying.

Girls and boys grow up seemingly the same heart attack olivia newton john verapamil 120mg overnight delivery, and they develop into two very different groups as they get older blood pressure chart record readings cheap 120 mg verapamil mastercard. It is great that you are concerned about your daughter‘s social interaction with boys because many parents do not take the time to arteria pulmonar cheap 80 mg verapamil fast delivery encourage or develop these relationships in the proper manner heart attack by demi lovato buy verapamil 80 mg overnight delivery. I would first encourage you to look into finding a good social story for your daughter to read. Social stories are great ways to teach children with Aspergers about social interactions. There are many books to choose from so make sure that you find a social story that is age appropriate for your daughter. If she is an older child, you may want to consider finding an age-appropriate novel related to social relationships between boys and girls and read it with her. She can ask you questions, and you can provide her with appropriate responses to her questions. It may be a good idea to monitor her during her interaction with her male friends. If you notice any behaviors that you do not like, you can talk to your daughter about it later when the two of you are alone. The two of you can continue to do this until you achieve the desired behaviors that you want to see. Try to find as many opportunities for your daughter to interact with as many other children as you possibly can. Activities like church functions, school activities, and neighborhood activities are great opportunities for your child to gain social understanding and appropriate interaction with boys. It is better that she comes to you for answers than to learn something incorrect from her peers. She will eventually come around and feel comfortable with these interactions thanks to you. As babies and young children, humans have the natural desire to relate and interact with others. As we get older, it becomes easier to tell when a person is lacking in social skills training. However, these services are costly and often out of reach for families dealing with Autism. Meet with the special education coordinator to discuss possible social skills training. While there may not be a true social skills therapy available, they may be able to accommodate her need in other ways. Many times members of these groups pool their knowledge and experience to form therapy groups and classes within the membership. By giving your teen plenty of social opportunities, you can enhance her social skills. Clubs, groups, church youth activities, and recreational sports are all fine opportunities to learn social skills. Use specific instances and happenings to teach your teen how to handle different social situations. An online search or local library search can lead to the perfect resource for you and your teen. Due to lack of insurance coverage for crucial Autism therapies, it can be a challenge to find appropriate social skills training. Friends are difficult to find and keep, are judgmental, and Aspie teens often become isolated socially. A special interest may encourage friendships with other teens with the same interest. Plan a couple of activities (a video, perhaps) in case they have difficulties thinking of what to do. Also, some high schools have support groups for teens with mentors who will help them navigate around school. She might try volunteering at a preschool, animal shelter, or other organization that encourages teen volunteers. Behavioural Therapy is highly recommended to teach her how to respond in teen social situations. You can work with her, too, by practicing and role-playing various social situations with her. See if you can get your daughter interested in the latest trends whatever they are, so that she has something to discuss with other girls. There are often different social groups and sets within schools, and by working on basic social skills your daughter will have a good chance of joining one of them in lines with her own interests. Monitor her closely and use parental controls to limit her access to only certain sites. Sometimes girls with Asperger‘s Syndrome have a difficult time expressing their true feelings. Stress, anxiety, frustration, and anger can get all mixed up together in a confused heap, causing a serious meltdown. Here are some factors that could explain this behavior, along with some additional thoughts. There could be several years‘ difference between the maturity level and the actual age. You must allow for this maturity difference and meet the girl at her actual maturity level. Watch for signs of sensory overload and try to remove her from the situation before she breaks down. If therapy is not an option, you can find books and videos to use at home to help her. Learning to deal with stress will help her avoid the meltdowns that are brought on by stressful situations. Meltdown control techniques like redirection and a safe zone will help when anger and stress have not been managed. A medical exam is always a good idea when you are dealing with complicated behavior. A doctor can check for medical causes, as well as refer her for therapy or counseling. Sometimes medications can make a huge difference in the life of a child with Asperger‘s Syndrome. While medication is not for everyone, it is a good idea to weigh all of your options when you have a violent child. Mood stabilizers and anti-anxiety medications 97 For Free Weekly Aspergers Tips It is hard to watch a child with Asperger‘s Syndrome struggle to get through her days without major complications. She will feel better about herself when she is in control of her actions and her entire family will be safer and happier. When your daughter reacts to a situation with a squeal or a scream, it is sure to give you (and everyone else) a jolt. It is sometimes said that children with Asperger‘s Syndrome do not have a filter‘. Emotions, reactions, thoughts, and comments, to name a few, are normally filtered somehow and we respond appropriately. Most people just know that there are times when you should not scream, cry, speak in anger, or make comments that may hurt someone‘s feelings. Children with Asperger‘s Syndrome do these things because they do not understand that they should not. Add in the sensory integration disorder that affects children with Asperger‘s Syndrome and your child can really keep you on your toes. It is possible that your daughter is under sensitive and needs a lot of sensory input. You can create a home therapy program by using books and videos that detail the different sensory activities. This therapy will give your daughter the tools she needs to think and behave the way she should in different situations.

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In an animal model heart attack pulse rate generic 80 mg verapamil amex, picolinic acid supplementation promoted negative zinc bal ance (Seal and Heaton heart attack pain in left arm discount 240 mg verapamil amex, 1985) hypertension 2012 verapamil 80mg discount, presumably by promoting urinary excretion heart attack or pulled muscle purchase verapamil 240 mg. Algorithms To date, a useful algorithm for establishing dietary zinc require ments based on the presence of other nutrients and food compo nents has not been established, and much information is still needed to develop one that can predict zinc bioavailability (Hunt, 1996). Algorithms for estimating dietary zinc bioavailability will need to include the dietary content of phytic acid, protein, zinc, and possibly calcium, iron, and copper. The results of single test meals for measuring zinc absorption, however, may be different from the long-term response of zinc absorption, as has been shown to be the case for iron (see Chapter 9). There is an unusually rapid physiologic decline in the zinc con centration of human milk and consequently in the zinc supplied to infants fed human milk during the first 6 months of lactation (Krebs et al. Concentrations of zinc in human milk decline from approximately 4 mg/L at 2 weeks to 3 mg/L at 1 month, 2 mg/L at 2 months, 1. This amount appears to be generous at ages 4 to 6 months when evaluated by zinc intake from human milk at this age, and human milk has been shown to result in weight gain and body lengths similar to those of infants provided complementary foods at 4 to 6 months (Dewey et al. A positive association between zinc content of human milk at 5 months and changes in the weight-for age Z scores for the 5 to 7-month interval have, however, been documented (Krebs et al. There is also some evidence, how ever, that growth-limiting zinc deficiency can occur in infants prin cipally fed human milk after the age of 4 months (Walravens et al. These factorial estimates are based on measurements of zinc intake of infants fed human milk, fractional absorption, and endogenous losses (Krebs et al. Integu mental and urine losses are from published calculations (Krebs and Hambidge, 1986). Singh and coworkers (1989) reported that approximately 32 percent of zinc in cow milk is bound to casein and the majority of the remaining zinc (63 percent) is bound to colloidal calcium phosphate. The absorption of zinc from human milk is higher than from cow milk-based infant formula and cow milk (Lonnerdal et al. The zinc bioavailability from soy formulas is significantly lower than from milk-based formulas (Lonnerdal et al. Zinc nutriture in later infancy is quite different from that in the younger infant. It is likely that neonatal hepatic stores, which may contribute to metabolically usable zinc pools in early postnatal life, have been dissipated (Zlotkin and Cherian, 1988). As a result, extrapolation from human milk in take during the 0 through 6 months postpartum period, which yields 2. Data from the Third National Health and Nutrition Examination Survey indicate that the median intake of zinc from complementary foods is 1. Thus, the average zinc intake from human milk and complementary foods is estimated to be approximately 2 mg/day (0. Excretion of endogenous zinc is used to esti mate the physiological requirement of zinc in older infants and young children. These endogenous zinc losses (intestinal, urinary, and integumental), therefore, are estimated by extrapolation from measured values for either adults (see “Adults Ages 19 Years and Older”) or younger infants. Intestinal losses vary directly with the quantity of zinc absorbed (see “Adults Ages 19 Years and Older”). The average intestinal excretion of endogenous zinc in infants aged 2 to 4 months who receive human milk is approximately 50 µg/kg/day (Krebs et al. There is a “critical” level of intestinal excretion of endogenous zinc Copyright © National Academy of Sciences. This critical level, derived from all available sets of data for adult men, yields an average excretion of 34 µg/kg/ day of zinc and is used for children beyond 1 year of age and adoles cents. Therefore, 50 µg/kg/day is used for older infants and 34 µg/ kg/day for children aged 1 through 3 years. It is recognized that this is an approximation, not only because of the extrapolation of values but also because intestinal excretion of endogenous zinc is strongly correlated with zinc absorption. After early infancy, excretion rates for children on a body weight basis seem to differ very little from adult values (Krebs and Hambidge, 1986). No data are available on the integumental losses in children, so estimates for children are derived from data in adult men (Johnson et al. There fore, the estimated total endogenous excretion of zinc is 64 µg/kg/ day for older infants and 48 µg/kg/day for children aged 1 through 3 years. These requirements have been estimated from chemical analyses of infants and adults, which give an average concentration of 20 µg/g wet weight of zinc (Widdowson and Dick erson, 1964). It is assumed that each gram of new lean and adipose tissue requires this amount of zinc. The average amount of new tissue accreted for older infants and young children is 13 and 6 g/ day, respectively (Kuczmarski et al. With the estimates above, the total amount of absorbed zinc re quired for infants ages 7 through 12 months is 836 µg/day (Table 12-2). The corresponding value for children ages 1 through 3 years is 744 µg/day (Table 12-3). Fractional absorption probably has the greatest variation of any of the above physiological factors, depending as it does on numerous factors including quantity of ingested zinc, nutritional status, and bioavailability. This value is based on studies of infants and young children reported by Fairweather-Tait and coworkers (1995) and Davidsson and co workers (1996). To calculate the dietary zinc requirement based on Copyright © National Academy of Sciences. Based on an average intake of 500 µg/day from human milk and a fractional absorption of 0. Therefore the estimated absorbed zinc required from complementary foods is 586 µg/day (836 – 250). In a 6-month, placebo-controlled, randomized zinc sup plementation study (Walravens et al. Com pared with placebo-treated control subjects, the zinc-supplemented children had a significantly greater increase in mean weight-for-age Z-scores. The calculated mean dietary intake at baseline for the placebo-treated children was 4. It is likely that this calculation errs on the low side because of the variability associated with 24-hour recall dietary information and because some children with weight-for-age greater than the tenth percentile are also likely to have mild growth limiting zinc deficiency. The nonintestinal endogenous losses and requirement for growth are based on data previously discussed (see “Infants and Children Ages 7 Months through 3 Years”). For this age group, the average intestinal losses are 34 µg/ kg/day of zinc and the amount of new tissue accreted is 7 g/day (Kuczmarski et al. Based on the summation of zinc losses and requirements for growth, the required amount of absorbed zinc for this age group is approximately 1. Some dietary data are available from children aged 4 through 8 years whose growth percentiles were at the lower end of the normal range and who were subjects in placebo-controlled, randomized trials of dietary zinc supplementation. No growth response was observed with zinc supplementation of healthy children of either gender, unselected for growth, whose average calculated zinc in take was 6. Estimates used for factorial analysis are similar for boys and girls, and therefore calculations are used to estimate a single average requirement for both genders. With use of the same values as for younger children, an average accretion of 10 g/day of new tissue (Kuczmarski et al. As determined by the extrapolation method described in Chapter 2, the average requirement for boys and girls is 6. Endogenous losses are calculated as for younger age groups by using the reference weights (see Chapter 2) with the addition of 100 µg/day of zinc to allow for calculated average se men or menstrual losses (see “Adults Ages 19 Years and Older”, which follows). Gender differences are sufficient at this age for boys and girls re quirements to be calculated separately. As determined by the sum mation of average zinc losses and the zinc requirement for growth (Kuczmarski et al. Based on the extrapolation method de scribed in Chapter 2, the average requirement for adolescent boys and girls is 9. With this approach, the principal indicator selected is the minimal quantity of absorbed zinc that is adequate to replace endogenous zinc losses. Step 1: Calculation of Endogenous Losses of Zinc via Routes Other than the Intestine.

Chi-Fishman and Sonies (2000) noted that when there was evidence of slit-like opening of the laryngeal vestibule during the sequential swallowing process there was evidence of trace penetration blood pressure zolpidem 80mg verapamil free shipping. Interestingly blood pressure cuff size generic 120 mg verapamil with mastercard, the penetrated material was expelled from the lar ynx on the next cycle of laryngeal elevation hypertension benign verapamil 240mg low cost. For the velopharyngeal system and the hyoid-laryngeal systems prehypertension numbers generic 120mg verapamil visa, the rapid and coordinated pattern of activation and partial deactivation is a cost-effective muscular adjustment during a repeating, sequential task. Another normal variation of sequential swallowing is the merging of two suc cessive boluses in the hypopharynx before the pharyngeal response is initiated. The rst bolus is usually accumulated deep in the pharynx, most likely the pyriform sinuses, with the incoming bolus propelled into the pharynx to merge with the ac cumulated bolus. Chi-Fishman and Sonies (2000) reported that when the bolus merging occurs the laryngeal vestibule is closed, but usually the hyoid and larynx are partially descended. Se quential swallows show slower oral to pharyngeal stage transition and pharyngeal transit durations, however. In sequential swallows the bolus enters hypopharynx and may even pause/dwell there momentarily before a pharyngeal swallow response is generated – a phenomenon not observed in a discrete swallow. Other characteristics unique to sequential swallowing pattern are: ‘movement momentum, prolonged sensory stimu lation and a heightened motor response’ (Chi-Fishman and Sonies, 2000: 1490). Clinical inferences Clinically there are a couple of important points to pull out from the differences between discrete and continuous swallows. In assessment there is the tendency to avoid continuous swallows for fear of mas sive aspiration. Certainly, if the individual has extremely poor swallow-respiratory coordination there are certain dangers to testing continuous cup drinking. Continuous drinking is more the norm, and as part of a progression towards more normal swallowing, it should also be assessed where the risk of frank aspiration is not extreme. Note also that in assessment of this variation radiologically the speech pathologist should accept triggering of the swallowing re ex from deeper in the pharynx as normal, and the possibility of normal penetration, which is promptly cleared with the next swallow. Fans of the milkshake will know there is nothing better than drinking this particular beverage through a straw. Daniels and Foundas (2001) investigated the physiology of sequential straw drinking in healthy young men. To what extent their ndings can be carried over to the elderly popu lation remains to be seen, nevertheless, they provide some important information worthy of consideration. In its simplest form, the straw allows us to deliver the bolus to the posterior part of the oral cavity. So for individuals with poor tongue strength, there is an advan tage in moving the bolus to the best point for swallow re ex initiation more ex pediently. Using the straw to promote posterior placement of the bolus in the oral cavity requires the buccal muscles, tongue and palatal muscles to work together to form suction, drawing the bolus into the mouth in a controlled manner. This is quite distinct from using respiratory force to ‘vacuum’ the bolus up through the straw and into the oral cavity. Note that if individuals inhale as they draw the liquid up the straw, they stand a very great chance of inhaling and thus aspirating the liquid. For healthy individuals there is approximately one swallow every second when drinking sequentially using a straw. For trivia buffs, the mean total volume swallowed in 10 s is 115ml with a range of 62ml to 168ml. There are three different patterns of hyolaryngeal excursion associated with sequential straw drinking. Type I is the most consistent pattern, with roughly equal evidence of the other two patterns. As noted in our discussions of the discrete bolus above, our expectation is for the swallow re ex to be initiated at least at the ramus of the mandible. In sequential straw drinking, the majority of swallows are initiated with the head of the bolus below the level of the valleculae. In sequential straw drinking it is also normal to accumulate a bolus in the phar ynx while the oral cavity takes up the next bolus, after which time the pharyngeal swallow re ex is usually triggered (Daniels and Foundas, 2001). This pattern of bolus accumulation was signi cantly associated with Type I hyolaryngeal excursion movements where the epiglottis returns to upright and the laryngeal vestibule opens after each swallow. Of more interest, however, is that there are also signi cant normal differences in site of swallow re ex initiation and handling of the bolus. Beginning with the oral preparatory phase, Hiiemae and Palmer (1999) found that hard solid foods are deposited on the depressed anterior surface of the tongue, whereas it was normal practice for soft foods to be scraped from a spoon by the upper incisors and collected on the anterior surface of the tongue as the spoon was withdrawn from the oral cav ity. In both instances, the posterior portion of the tongue rides high in the mouth so that the overall con guration resembles something of a ski slope with the peak at the posterior portion of the mouth and the low point at the anterior end of the mouth. This type of con guration encourages the bolus to remain within the oral cavity and provides a physical barrier to premature escape into the pharynx. Ingestion of a solid bolus requires mastication and rotary lateral movement of the mandible to bring the teeth edges together to break the food down. Food is pushed to wards the molars by the tongue rising anteriorly and squeezing the bolus against the hard palate. Food is also intermit tently pulled back by the tongue for repositioning and further mastication (Hiiemae and Palmer, 1999). The food may then be segmented into portions that have been adequately masticated and portions that still require additional mastication. Por tions that have been adequately masticated are ‘stored’ on the posterior surface of the moving tongue, with further morsels joining the accumulating bolus. Note that food can continue to be processed while ‘swallow-safe’ food accumulates to form a bolus. The ‘swallow-safe’ bolus that accumulates on the tongue appears to maintain its position on the still moving tongue without any particular anatomical constraints. In fact the tongue to soft palate contact is both intermittent and irregular (Hiiemae and Palmer, 1999). The addition of food to the oral cavity and the actions of mastication also activate the salivary glands. Saliva mixes with the bolus to moisten it, which acts as a binding agent, allowing the food to be formed into a cohesive bolus, and enzymes within the saliva assist in chemically breaking the bolus down, thereby initiating the ‘digestive process’. Note that for a solid bolus, the act of mastication and bolus preparation signi cantly increases this time frame. Another variation between liquids and solids is that we can consume liquids at higher temperatures than solids (Longman and Pearson, 1987). For solids, chewing sequences may involve multiple swallows to clear the bolus from the oral cavity (Hiiemae and Palmer, 1999). As noted above in the discussion of single bolus swallows, it is accepted that the swallow re ex should be initiated at the faucial arches or when the bolus crosses the anterior margin of the manidibular ramus as seen radiographically (Bisch et al. However, it rarely reaches the pyriform sinuses before a swallow response is initiated (Dua et al. It would also appear that the swallowing system is more tolerant of foodstuffs squirrelled in the valleculae or even the pyriform sinuses than that of the epiglottal edges. The epiglottis is one of the physical ‘gatekeepers’ to ensure safety of the respiratory system. Clinical inferences the normal physiological differences detailed above must be borne in mind when performing both the clinical bedside and radiographic assessments of swallowing. It is normal for food to enter the upper portion of the pharynx prior to a swallow re ex being initiated. It is normal to take 10 s or more to masticate a mouthful or bite of a solid food and for multiple swallows to be used to clear the oral cavity of food. Poor understanding of the normal physiology can place individuals on unnecessary modi ed diets. Regular thin uids require excellent muscle control (oral and pharyngeal) and accurate timing between the swallowing system and the respiratory system to ensure that they are safely in gested. When an individual presents with dysphagia, they often lack the necessary muscular control and/or the sensory input integral to generating a timely and ef cient muscular response. The problems with thin uids are that • they are not particularly cohesive and consequently tend to fracture or ‘fall apart’ en route if not swallowed ef ciently; and • because of their fracturability they are highly volatile and move very quickly. If it is not possible to ‘ x’ the swal lowing problem, then one looks at ways of compensating for it (see Chapter 11). Speech pathologists have been using thickened uids therapeutically for years in an attempt to maintain oral hydration.

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