Introduction to communication in health, social care or children’s and young people’s setting Essay

It is important when communicating with people to observe their reactions, this is important for many reasons as it can give us some insight and indication to whether a person has understood us or not, if we have given any direction or are trying to pass on information. By looking at a person’s reactions we get an idea also to how what we are saying is being received. For example if we say something to a colleague or parent we can tell by a person’s reaction if what we have said has made or is making them happy, sad, confused, angry, outraged, worried or excited. If the persons face starts to change to look cross or frown then there is a chance you may offended, upset or made them angry, whereas if a person is smiling, laughing, joking or bright eyed they may be happy or excited. If we can learn to notice and judge these reactions we can adapt and adjust our communication by our tone or language we are using accordingly. It is not only important so you can determine whether what u have tried to convey has been understood. Reactions and body language are a person’s unspoken words or feelings and can at times be up to 30% of communication. If there was someone in my setting whose reactions and or body language become or was different to that of their normal behaviour or that of expected normal behaviour and I was concerned it would be part of my job role to pick up on this and also to communicate this to my appropriate senior within the setting. In our settings there may be many barriers a person might face in terms of communicating with one another. A common barrier is language. Others might include a learning difficulty, hearing impairment, emotional state of a person, intellect of a person, noise a sight and/or speech impairment. The list is endless some barriers are social barriers, some emotional, some environmental. Not only is it part of our role to recognise these barriers it is also our responsibility to try to reduce overcome and eliminate them when trying to communicate effectively. An example of this would be if I had a child, parent or colleague in my setting who had a problem speaking or understanding English I may use body language and facial expressions as a form of communicating and conveying a thought or feeling. Another way I could overcome a language barrier might be to make use of one of the services the setting provides like a translator or interpreter. All of these methods are acceptable and effective ways of overcoming language barriers. Another example of a barrier to communicating would be if I was trying to have a confidential talk with a parent but my environment was crowded and noisy, the noise would be a barrier as it might prohibit us from fully hearing one another and if it is crowded we may not be able to talk confidentially without others hearing or listening so to eliminate the barriers it would be necessary to go somewhere private and less noisy. Confidentiality means information that is privileged private not to be shared or exposed to or by anyone. This could be something that is said, a letter, a document a piece of information that is confidential. In our setting it is essential anyone disclosing and sharing information with us know that we will not share this information unless it is for the well being and safeguarding of the child. In our setting we are constantly being given confidential information whether it be medical need dietary needs educational requirements of or child protection issues. Generally we do not share confidential information with everyone but it is so important that the appropriate people and or organisations are informed and aware. If a child had special dietary requirements we would need to share this information with the staff who supervise the meal/snack times and also the staff in the kitchen. Another time you might share information would be if you had concerns about a childs protection and wellbeing outside of the setting. In these circumstance it is our role to sensitively disclose any concerns, information or observations on that young person to our line manager supervisor or someone in a higher chain of command at the setting to us.

Research Paper on Renewable Energy Essay

Research Paper In March 2011, a 9.1 magnitude earthquake hit the pacific coast of Japan, generating up to 133ft tall tsunami waves, which obliterated everything up to 6 mi. inland. According to the NPA (National Police Agency) of Japan, 24, 656 people were affected by this catastrophe, which include the deceased, injured, and missing. The tsunami also affected three of the six nuclear reactors of the Fukushima Nuclear Power Plant causing leakage of radioactive material. Many workers and even civilians worked hard to contain the harmful material for it to stop contamination in other areas, but it already spread. A The Associated Press news writer states, â€Å"The massive amount of radioactive water is among the most pressing issues affecting the cleanup process, which is expected to take decades. There have been other leaks of contaminated water at the plant, and some of it is entering the sea.† Today, the radioactive material has spread out and covered almost all of the Pacific Ocean, harmi ng wild life and contaminating our food. Why do governments and corporations make and allow this technology to be used if it can contaminate our world and us? There are better and more beneficial sources for renewable energy other than nuclear power. Technology has advanced tremendously in the past hundred years. We have created massive destruction weapons, medical equipment, electronics, Internet, etc. I would consider renewable energy sources to fall into this list. Some renewable energy sources would be solar power, wind power, hydroelectricity, and nuclear power. There has been much debate between whether nuclear power should be considered a renewable energy source or not. Some people argue it shouldn’t since â€Å"it produces harmful waste byproducts and relies on extractive industries to procure fuel like uranium† (Kanter). Unlike nuclear power, other renewable energy sources, such as hydroelectricity, don’t radiate harmful material to our environment. Then there are others who argue it should be considered a renewable resource. New York Times journalist indicates, â€Å"pro-nuclear officials from countries including France have been trying to brand the technology as renewable, on the grounds that it p roduces little or no greenhouse gases† (Kanter). I personally do not consider nuclear power a renewable resource. The use of both nuclear and renewable  energy has expanded largely compared to what it was 50 years ago. Most countries like USA, France, and Russia use nuclear power to produce most of their electricity. Countries like Norway, Iceland, and Paraguay mostly use renewable energy sources to produce their electricity and they notice the great impact this technology does towards the reduction of CO2 in our atmosphere. 90% of Paraguay’s electricity is provided from the Itaipu dam. The dam removes 67.5 million tons of CO2 a year. Iceland’s electricity supply is 100% renewable energy and its sources are both geothermal and hydropower. There is so much geothermal capacity that there is discussion about whether or not an interconnector can be built into the UK grid. Norway’s top three sources of electricity are hydroelectric, geothermal, and wind sources. Norway serves the export market by selling their renewable energy to other countries since they only use 24% of 98% g enerating capacity. These are countries that are making a change in the environment. Solar power is being used very much today. Most of the housed in LA, California have some sort of solar panel. Houses are getting their own little renewable energy machine that saves the household money each month, since most don’t even pay electrical bills from excessive energy. When I found out about this, I told my stepfather we should research on getting solar panels for our house. The cost for solar panels varies from 3,000 – 5,000 for 12 panels. The cost of the panels plus the installation would be too much for most people; that’s why solar paneled houses are rarely seen. Trying to be eco-friendly isn’t cheap. People are recently realizing that we have been getting our planet contaminated all these years and that we have to do something about it now. Flyers, ads, and people are telling us we need to stop littering and recycle to clean and care for our planet. Those things do help, but I think there are worse things our planet is being exposed to than just trash. Nuclear power plants, that we created, are being used for energy all over the world and we are not thinking about the repercussions they might bring. We are gambling with our sensitive planet and our lives. What if something like Fukushima happens again, and even worse, what if it happens like in Chernobyl? Do we as the human race want to take that chance? What could this do to our health? The author of â€Å"Nuclear Power is Not the Answer† states, â€Å"no dose of radiation is safe, and all radiation is cumulative. Each dose received adds to the risk of developing  cancer or mutating genes in the reproductive cells† (Caldicott, 44). Caldicott also thinks, â€Å"80% of cancers that we see are caused by environmental factors, whereas only 20% are inherited† (Caldicott, 44). All governments and all corporations around the world need to put a stop to harmful material being created and exposed. It needs to be stopped not only for our plant, but also for our lives and health. We will destroy our planet if we keep creating things like nuclear power plants. Are we going to wait for an earthquake, hurricane, or even terrorist attack to happen for us to realize the negative effect nuclear power can cause? Some countries realize this and that is why they use 100% renewable energy from non-toxic sources and machinery like hydroelectricity, wind power, and solar power. Those harmful chemicals don’t just hurt our planet, but they hurt our health as well. We need to realize what we are doing wrong and put a stop to it, before it’s too late for everything. There are better and more beneficial sources for renewable energy other than nuclear power. Works Cited â€Å"Damage Situation and Police Countermeasures associated with 2011 Tohoku district.† Chart. National Police Agency of Japan. Emergency Disaster Countermeasures Headquarters, 2014. Web. 10 Apr. 2014. â€Å"Japan Nuclear Plant Suffers Worst Radioactive Water Leak.† The Associated Press (2013). CBC. Web. 10 Apr. 2014. Kanter, James. â€Å"Is Nuclear Power Renewable?† New York Times. New York Times, 9 Nov. 2003. Web. 10 Apr. 2014 Caldicott, Helen. Nuclear Power is Not the Answer. Melbourne: The New Press, 2006. Print.

Stages of Study and Evaluation of Internal Control Essay

The stages/activities involve in studying and evaluating internal control are: A. Obtaining an understanding of the entity’s internal control structure. B. Assessing the preliminary level of control risk. C. Obtaining evidential matter to support the assessed level of control risk. D. Evaluating the results of evidential matter. E. Determining the necessary level of detection risk. STAGE A. Obtaining an understanding of the entity’s internal control structure. In planning the audit examination, each of the five components of internal control must be studied and understood by the auditor to enable him to (1) identify types of potential misstatements; (2) consider factors that affect the risk of misstatement; and (3) begin to design appropriate testing procedure. Understanding the Control Environment The auditor should obtain sufficient knowledge of the control environment to understand management’s and the board of director’s attitude, awareness, and actions concerning the control environment. The auditor should concentrate on the substance of management’s policies, procedures, and related actions rather than their form because management may establish appropriate policies and procedures but not act on them. Understanding Control Procedures Because some control procedures are integrated in specific components of the control environment and accounting system, as the auditor obtains an understanding of the control environment and accounting system, he is also likely to obtain knowledge about some control procedures. The auditor should consider the knowledge about the presence or absence of the control procedures obtained from the understanding of the control environment and accounting system in determining whether it is necessary to devote additional attention to obtain an understanding of control procedures to plan the audit. Understanding the Accounting and Internal Control Systems To understand the design of the accounting information system, the auditor determines (1) the major classes of transactions of the entity; (2) how  those transaction are initiated; (3) what accounting records exist and their nature; (4) how transactions are processed from initiation to completion, including the extent and nature of computer use; (5) the nature and details of the financial reporting process followed. Typically, this is accomplished and documented by a narrative description of the system or by flowcharting. The operation of the accounting information system is often determined by tracing one or few transactions through the system (called a transaction walk-through). Information controls relating to the accounting system are concerned with achieving objectives such as: Transactions are executed in accordance with management’s general or specific authorization. All transactions and other events are promptly recorded in the correct amount, in the appropriate accounts and in the proper accounting period so as to permit preparation of financial statements in accordance with an identified financial reporting framework. Access to assets and records is permitted only in accordance with management’s authorization. Recorded assets are compared with the existing assets at reasonable intervals and appropriate action is taken regarding any differences. When obtaining an understanding of the accounting and internal control systems to plan the audit, the auditor obtains knowledge of the design of the accounting and internal control systems. When the transactions selected are typical of those transactions that pass through the system, this procedure may be treated as part of tests of control. The nature, timing, and extent of the procedures performed by the auditor to obtain an understanding of the accounting and internal control systems will vary with, among other things: The size and complexity of the entity and of its computer system. Materiality considerations. The type of internal controls involved. The nature of the entity’s documentation of specific internal controls. The auditor’s assessment of inherent risk. Ordinarily, the auditor’s understanding of the accounting and internal control systems significant to the audit is obtained through previous with the entity and is supplemented by: a. Inquiries of appropriate management, supervisory and other personnel at various organizational levels within the entity, together with reference to documentation, such as procedures  manuals, job descriptions, and flow charts; b. Inspection of documents and records procedure by the accounting and internal control systems; and c. Observation of the entity’s activities and operations, including observation of the organization of computer operations, management personnel and the nature of transaction processing. The auditor determines the policies, procedures, methods, and records placed in operation by inspecting documents and directly observing the policies and procedures in use. The auditor can examine actual, completed documents and records to bring the contents of the manual to life and better understand them. In addition, the auditor can observe client personnel in the process of preparing them and carrying out their normal accounting and control activities. This further enhances understanding and knowledge that controls have been placed in operation. Documentation of Understanding The auditor should document the understanding of the entity’s internal control structure elements obtained to plan the audit. The form and extent of this documentation is influenced by the size and complexity of the entity, as well as the nature of the entity’s internal control structure. Generally, the more complex the internal control structure and the more extensive the procedures performed, the more extensive the auditor’s documentation should be. 1. Internal Accounting Control Questionnaire Internal accounting control questionnaire contains a series of questions designed to detect control weaknesses. Most questionnaires are designed to yield â€Å"yes†, â€Å"no†, or â€Å"not applicable† answers to the questions. A â€Å"yes† answer generally indicates a satisfactory degree of internal accounting control while a â€Å"no† answer indicates a possible weakness in control or at least indicates that further investigation is required. If the weakness is material, them it should be reported to a senior management, the board of directors, and the audit committee. â€Å"Material weakness is one in which the procedures or degree of compliance with the procedures fail to provide reasonable assurance that material errors or irregularities would be prevented or promptly detected during the accounting process.† In completing the internal control questionnaire, the auditor should consider the  following critical aspects: 1. Is the system of internal control sound? 2. If it is not reliable, what errors might occur? 3. What alternative audit procedures should be adopted if the system is unreliable? Advantages They provide audit assurance that attention is given to presence or absence of all controls listed and that certain features of the system are not overlooked. They provide a means of obtaining uniform documentation of internal control system reviewed. They provide inexperienced audit staff members with guidance in performing internal control reviews. They facilitate the early detection of potential weaknesses in the system. Disadvantages Auditor may view the questionnaire device for accomplishing an automatic evaluation of internal control. Controls listed on questionnaire may not suit the particular circumstances of a specific audit. The auditor may overlook pertinent control not included in the questionnaires. 2. Flowcharts Flowchart is a symbolic diagram of a specific part of an internal accounting control system indicating the sequential flow of data and/or authority. An internal control flowchart uses standardized symbols, interconnecting lines, and annotations to represent information, document, and document flow. It provides a pictorial overview of a client’s internal control activities. It illustrates the interaction of individuals, records, and control related to a particular department or class of transactions. Internal control flowcharts generally reflect the segregation of duties by using a column across the top to reflect different departments and the flow of documents and the flow of documents from left to right. Advantages Easily understood. Since flowcharts provide a visual description supplemented by a written narrative, they are more easily understood. Better overall picture or complex system. A complex system may be reduced to a one or two-page flowchart which might otherwise require a 15-page internal control questionnaire or a 10-page narrative memo. Parallels EDP documentation. EDP systems are commonly documented with flowcharts which make it easier for EDP  purchase personnel to relate to the auditors. It is easy to update. Disadvantages Higher level of knowledge and training are required to prepare a good flowchart of a complex system. Flowcharts take more time to prepare and require more knowledge. It is more difficult to spot internal control weakness. The ff. questions should be answered before a flowchart is prepared: 1. Who performs the various functions in the routine? 2. Why are these functions performed? 3. What work is performed, and is the work considered input or output? 4. When are the functions performed and in what sequence? 5. How are the functions performed and in what sequence? Conference with senior management, supervisors, and employees using the above checklist should be conducted by the independent auditor before flowcharting the routine. In addition, copies of all forms, documents and reports used in the routine to be flowcharted should be obtained. A primary purpose of the internal control flowchart is to communicate effectively. The ff. techniques should assist in meeting this goal: Standardized symbols. Auditors use a uniform set of symbols developed by the American National Standards Institute (ANSI). Flowlines. The flow of documents should be from top to bottom and left to right. Arrowheads may be used on all lines and should be used when the flow is not standard or is bi-directional. Documents. When a document is created, its source should be indicated. Multiple-document symbols are required when multiple copies of the document are prepared. The disposition of every copy or each document should be shown. Processing. Processing symbols are used to identify any procedures applied to documents such as their being filed. Annotations. Comments and explanations should be used to make the flowchart easier to understand or more complete. The ff. guidelines may be useful in preparing a flowchart: Determine the class of transactions or transaction cycle to be flowcharted. Obtain an understanding of internal control by making inquiries of client personnel, observing employee activities, and examining documents, records, and policies and procedures manuals. Organize the flowchart into columns, using a different column for each department, function, or individual. Draw a sketch of the flowchart. Draw the flowchart and insert comments and annotations. Test the flowchart for completeness by following a few transactions through the chart. 3. Narrative Description A narrative is a written description of a particular phase or phases or a control system. Although useful for describing simple systems, narratives may be adequate when a system is complicated or frequently revised. If the systems are extensive and/or complex, separate narratives may be prepared for a smaller groups of control which relate to specific classes of transactions or accounts. Some auditor prepare narrative descriptions to accompany internal control questionnaire or flowcharts in order to provide information not otherwise included. Advantages: Narrative is flexible and may be tailor-made for engagement. Requires a detailed analysis and thus forces auditor to understand functioning of the system. Disadvantages: Auditor may not have the ability to describe the system correctly and concisely. This may require more time and careful study. Auditor may overlook important portions of internal control system. A poorly written internal accounting control narrative can lead to a misunderstanding of the system thus resulting in the improper design and application of compliance tests. 4. Internal Control Checklist This contains a detailed enumeration of the methods and practices which characterize good internal control or of item to be considered in reviewing internal control. 5. Decision tables In this approach, the system is depicted as decision points. Advantages and disadvantages are similar to those of the flowchart approach. STAGE B. ASSESSING THE PRELIMINARY LEVEL OF CONTROL RISK After obtaining an understanding of the accounting and internal control systems, the auditor should make a preliminary assessment of control risk, at the assertion level, for each material account balance or class of transactions. The preliminary assessment of control risk is the process where the auditor evaluates the effectiveness of a client’s internal control policies and procedures in preventing or detecting material misstatements in the financial statement assertions, namely: (1)/(2) Existence/ Occurrence. Procedures that require documentation, approvals, authorization, verification, and reconciliations. (3) Completeness. Procedures that ensure that all transactions that occur are recorded such as accounting for numerical sequence of documents. (4) Right and obligations. Procedures that ensure that the entity has a right to asset or an obligation to pay arising from the transaction. (5)/(6) Valuation/ Measurement. Procedures that ensure that a proper price is charged and that mathematical accuracy are present in recording and in developing the accounting records and financial statement. (7) Presentation and Disclosure. Procedures that indicate that a review has been made to ascertain that a transaction has been recorded in the proper account and that financial statement disclosure have been reviewed by competent personnel. The process of arriving at the auditor’s assessment of control risk is an iterative process that is refined as the auditor’s obtain more and more evidence about the effectiveness of various internal control policies and procedures. After obtaining the understanding of the internal control structure, the auditor may assess control risk at the maximum level. The term maximum level is used in this section to mean the greatest probability that a material misstatement that could occur in a financial statement assertion will not be prevented or detected on a timely basis by an entity’s internal control structure. Control risk may be assessed in quantitative terms, such as percentages, or in nonquantitative terms that range, for example, from a maximum to a minimum. Assessing control risk at below the maximum level involves- Identifying specific internal control structure policies and procedure relevant to specific assertions that are likely to prevent or detect material misstatements in those assertions. Performing tests of control to evaluate the effectiveness of such policies and procedures. The preliminary assessment of control risk for a financial statement assertion should be high unless the auditor: a. Is  able to identify internal controls relevant to the assertion which are likely to prevent or detect, and correct a material misstatement; and b. Plans to perform tests of control to support the assessment. Assessing Inherent Risk In developing the overall audit plan, the auditor should assess inherent risk at the financial level. In developing the audit program, the auditor should relate such assessment to material account balances and classes of transactions at assertion level, or assume that inherent risk is high for the assertion. To assess inherent risk, the auditor uses professional judgement to evaluate numerous factors, examples of which are: At the Financial Statement Level The integrity of management. Management experience and knowledge and changes in management during the period. Unusual pressure on management. The nature of the entity’s business. Factors affecting the industry in which the entity operates. At the Account Balance and Class of Transactions Level Financial statement accounts likely to be susceptible to misstatement. The complexity of underlying transactions and other events which might require using the work of an expert. The degree of judgment involved in determining account balances. Susceptible of asset to loss or misappropriation. The completion of unusual and complex transactions. Transactions not subjected to ordinary processing. Relationship between the Assessment of Inherent and Control Risks Management often reacts to inherent risk situations by designing accounting and internal control systems to prevent or detect, and correct misstatements and therefore, in many cases, inherent risk and control risk are highly interrelated. In such situations, if the auditor attempts to assess inherent risk and control risks separately, there is a possibility of inappropriate risk assessment. As a result, audit risk may be more appropriately determined in such situations by making a combined assessment. Identification of Specific Internal Control Policies to Specific Assertions  Auditors are interested in control activities because they assist in establishing the validity of financial statement assertions. Controls that enhance the reliability of the financial statements may be preventive controls or detection controls. Preventive controls avoid errors and irregularities while detection controls recognizing that error will occur even under ideal conditions provide for a â€Å"double-check† to locate significant occurrences after the fact. If an entity’s controls are found to be effective, the auditor may reduce the selected auditing procedures to test a group of assertions. Control activities may provide direct evidence about the many assertions. In identifying internal control structure policies and procedures relevant to specific financial statement assertions, the auditor should consider that the policies and procedures can have either a pervasive effect on many assertions or a specific effect on an individual assertion, depending on the nature of the particular internal control structure element involved. Conversely, some control procedures often have a specific effect on an individual assertion embodied in a particular account balance or transaction class. The objective of procedu res performed to obtain understanding of the internal control structure is to provide the auditor with knowledge necessary for audit planning. The objective of test of controls is to provide evidential matter to use in assessing control risk. When the auditor concludes that procedures performed to obtain the understanding of the internal control structure also provide evidential matter for assessing control risk, he should consider the degree of assurance provided by that evidential matter. Although such evidential matter may not provide sufficient assurance to support an assessed level of control risk that is below the maximum level of certain assertions, it may do so for other assertions and thus provide a basis for modifying the nature, timing, or extent of the substantive tests that the auditor plans for those assertions. STAGE C. OBTAINING EVIDENTIAL MATTER TO SUPPORT THE ASSESSED LEVEL OF CONTROL RISK The auditor obtains evidential matter to enable him to determine the proper level of control risk by performing test of controls or compliance tests on selected policies and procedures. Compliance procedures are designed to obtain reasonable assurance that those internal controls on which tests requiring inspection of documents supporting transactions to gain evidence that controls have operated  properly and inquiries about and observation of controls which leave no audit trail. Test of Controls Procedures directed toward either the effectiveness of the design or operations of an internal control structure policy or procedure are referred to as tests of controls. Tests to obtain such evidential matter ordinarily include procedures such as inquiries of appropriate entity personnel, inspection of documents and reports, and observations of the application of specific internal control structure policies and procedures. Tests of control are performed to obtain audit evidence about the effectiveness of the: a. Design of the accounting and internal control systems, that is, whether they are suitably designed to prevent or detect and correct material misstatements; and b. Operation of the internal controls throughout the period. The auditor should obtain audit evidence through tests of controls to support any assessment of control risk which is less than high. The lower the assessment of control risk, the more support the auditor should obtain that accounting and internal control sy stems are suitably designed and operating effectively. When obtaining audit evidence about the effective operation of internal controls, the auditor considers how they were applied, the consistency with which they were applied during the period and by whom they were applied. The concept of effective operation recognizes that some deviations may have occurred. Deviations from prescribed controls may be caused by such factors as changes in key personnel, significant seasonal fluctuations in volume of transactions and human error. In computer information system environment, the objectives of tests of controls do not change from those in a manual environment; however, some audit procedures may change. The auditor may find it necessary, or may prefer, to use computer-assisted audit techniques. STAGE D. EVALUATING THE RESULTS OF THE EVIDENTIAL MATTER Based on the results of the tests of controls, the auditor should evaluate whether the internal controls are designed and operating as contemplated in the preliminary assessment of control risk. The evaluation of deviations may result in the auditor concluding that the assessed level of control risk needed to be revised. In such cases, the auditor would modify the nature,  timing, and extent of planned substantive procedures. The conclusion reached as a result of assessing control risk is referred to as the assessed level of control risk. In determining the evidential matter necessary to support a specific assessed level of control risk below the maximum level, the auditor should consider the characteristics of evidential matter about the control risk. Generally, however the lower the assessed level of control risk, the greater the assurance the evidential matter must provide that the internal control structure policies and procedures relevant to an assertion are designed and operating effectively. Ordinarily, the auditor’s observation provides more reliable audit evidence than merely making inquiries. However, audit evidence obtained by some tests of controls, such as observation, pertains only to the point in time at which the procedures was applied. The auditor may decide, therefore, to supplement these procedures with other tests of control capable of providing audit evidence about other period of time. In determining the appropriate audit evidence to support a conclusion about control risk, the auditor may consider the audit evidence obtained in prior audits. In a continuing engagement, the auditor will be aware of the accounting and internal control systems through work carried out previously but will need to update the knowledge gained and consider the need to obtain further audit evidence of any changes in control. The auditor in addition, should consider whether the internal controls were in use throughout the period. An audit of financial statements is a cumulative process; as the auditor assesses control risk, the information obtained may cause him to modify the nature, timing, or extent of the planned tests of controls for assessing control risk. The evaluation is based on the effectiveness of the entity’s control structure in preventing and/pr detecting material misstatements, as determined by the tests of controls. STAGE E. DETERMINING THE NECESSARY LEVEL OF DETECTION RISK The auditor uses the acceptable level of detection risk to determine the nature, timing, and extent of the auditing procedures to be used to detect material misstatements in the financial statement assertions, auditing procedures designed to detect such misstatements are referred to in this section as substantive tests. The level of detection risk relates directly to the auditor’s substantive procedures. The auditor’s control risk  assessment, together with the inherent risk assessment, influence the nature, timing, and extent of the substantive procedures to be performed to reduce risk, and therefore audit risk, to an acceptably low level. In this regard the auditor would consider: a. The nature of substantive procedures, for example, using tests directed toward independent parties outside the entity rather than tests directed toward parties or documentation within the entity, or using tests of details for a particular audit objectives in addition to analytical procedures; b. The timing of substantive procedures, for example, performing them at period rather than at an earlier date; and c. The extent of substantive procedures, for example, using a larger sample size. As the acceptable level of detection risk decrease, the assurance provided from substantive tests should increase. Consequently, the auditor may do one or more of the ff Change the nature of substantive tests from a less effective to a more effective procedures, such as using tests directed toward parties or documentation within the entity Change the timing of substantive tests, such as performing them at year-end rather than at interim date. Change the extent of substantive tests, such as using a larger sample size. There is an inverse relationship between the detection risks and the combined level of inherent and control risks. The substantive tests that the auditor performs consist of tests of details of transactions and balances, and analytical procedures. The objective of tests of details of transactions performed as substantive tests is to detect material misstatements in the financial statements. The auditor should recognize, however, that careful consideration should be given to the design and evaluation of such tests to ensure that both objectives will be accomplished. Audit Risk in the Small Business The auditor needs to obtain the same level of assurance in order to express an unqualified opinion on the financial statements of both small and large entities. However, many internal controls which would be relevant to large entities are not practical in the small business for example is the segregation of duties. In circumstances where segregation of duties is  limited and audit evidence of supervisory control is lacking, the audit evidence necessary to support the auditor’s opinion on the financial statements may have to be obtained entirely through the performance of substantive procedures. How Adequacy or Inadequacy of Internal Control Affects Audit Procedures The primary reason for studying and evaluating internal control is to provide a basis for relying upon the system and for determining the extent of year-end substantive tests to be performed. There is an inverse relationship between the effectiveness of internal control and the extent of detailed audit procedures; more effective system requires less detailed testing. Strengths and weaknesses identified during the evaluation of internal accounting control and tests of compliance will affect the nature, timing, and extent of audit procedures. The audit is not specifically designed to search for errors or irregularities, although during the study and evaluation of internal accounting control system and the performance of substantive tests, errors, or irregularities may be discovered. The auditor must consider the audit implication when errors or irregularities are likely to exist. Documentation of the Assessed Level of Control Risk The auditor should document in the working papers. a. The understanding obtained of the entity’s accounting and internal control systems; b. The assessment of control risk. When control risk is assessed at less than high, the auditor would also document the basis for the conclusions. Figure 11.2 Relationship of Effectiveness of Internal Control and Substantive Tests Controls initially considered effective Controls initial not considered effective or not cost efficient Reduce control risk Assess control risk at maximum (100%) Reduce acceptable risk of overreliance on internal control Acceptable risk of overreliance on internal control- 100% (maximum) Perform tests of control (inquiries, inspection, observation, and reperformance) Perform no tests of controls Increase detection risk Decrease detection risk Reduce planned substantive test 1. Use less persuasive substantive tests. 2. Perform the substantive tests at interim date. 3. Decrease extent of substantive test by selecting a smaller sample size. Perform extensive substantive testing 1. Use more effective substantive tests. 2. Perform substantive tests at year-end 3. Increase extent of substantive tests by selecting a larger sample size. Communication of Performance, Improvements and Observations in Internal Control Management. As a result of obtaining an understanding of the accounting and internal control systems and tests of controls, the auditor may become aware of weaknesses in the systems. The auditor should make the management aware, as soon as practical and at an appropriate responsibility, of material weaknesses in the design or operation of the accounting and internal control systems, which have come to the auditor’s attention. The communication to management of material weaknesses would ordinarily in writing. Management letter may be made that will contain constructive suggestions or improvements in internal control or other suggestions for increased efficiency in operations. This letter is considered a by-product rather than the aim of the audit and is often completed sometimes after the completion of the field work. If however, the auditor identifies material weaknesses, he has a professional responsibility to communicate them to both senior management and the board of directors. The auditor should issue a written report at the earliest possible that it is documented in the work papers. Reportable Conditions Specifically, these are the matters coming to the auditor’s attention that, in his judgement, should be communicated to the audit committee because they represent significant deficiencies in the design or operation of the internal control structure, which could adversely affect the organization’s ability to record, process, summarize, and report financial data consistent with the assertions of management in the financial statements. Examples of reportable conditions are as follows: Deficiencies in internal control  structure design Inadequate overall internal control structure design Absence of appropriate segregation of duties consistent with appropriate control objectives. Absence of appropriate reviews, and approvals of transactions, accounting entries, or systems output. Inadequate procedures for appropriately assessing and applying accounting principles. Inadequate provisions for the safeguarding of assets. Absence of other internal control techniques considered appropriate for the type and level of transaction activity. Evidence that a system fails to provide complete and accurate output that is consistent with objectives and current needs because of design flaws. Failures in the operation of the internal control structure Evidence of failure of identified controls in preventing or detecting misstatements of accounting information Evidence that a system fails to provide complete and accurate output consistent with the entity’s control objectives because of the misapplication of control procedures. Evidence of failure to safeguard assets from loss, damage, or misappropriation. Evidence of intentional override of the internal control structure by those in authority to the detriment of the overall objectives of the system. Evidence of failure to perform tasks that are part of the internal control structure, such as reconciliation not prepared or not timely prepared. Evidence of willful wrongdoing by employees or management. Evidence of manipulation, falsification, or alteration of accounting records or supporting documents. Evidence of intentional misapplication of accounting principles. Evidence of misrepresentation by client personnel to the auditor. Evidence that employees or management lack the qualifications and training to fulfill their assigned functions. Others Absence of sufficient level of control consciousness within the organization Failure to follow up and correct previously identified internal control structure deficiencies. Evidence of significant or extensive undisclosed  related party transactions. Evidence of undue bias or lack of objectivity by those responsible for accounting decisions. Reporting- Form and Content Conditions noted by the auditor that are considered reportable under this section or that are the result of agreement with the client should be reported, preferable in writing. If the information is communicated orally, the auditor should document the communication by appropriate memoranda or notations in the working papers. Any report issued on reportable conditions should: Indicate that a purpose of the audit was to report on the financial statements and not to provide assurance on the internal control structure. Include the definition of reportable conditions.  Include the restriction on distribution as discussed in the previous paragraph. If no reportable conditions are found, an auditor may not issue a letter stating that. Such a letter may mislead users by implying a greater level of assurance about the lack of any significant deficiencies than the auditor could really provide. However, an auditor may issue a letter indicating that no material weaknesses were found during the course of an audit.

Sweden and German gender inequalities in employment Essay

Sweden and German gender inequalities in employment - Essay Example The EU notes that, â€Å"across Europe women earn on average 17.8% less than men†, meaning that Sweden is slightly above the median and Germany is almost 4.5% below it. The inclusion of a EU-wide average facilitates comparability. In large measure the gender pay gap directly expresses that women do not receive equal pay for work of equal value. However, it still does not adequately explain the nuances of the gender pay gap and inequality in employment. (EC, 2010) The existence of a 'glass ceiling' barriers and limits to promotions is also a factor. If women are denied access to the highest paying (and most influential) management positions this will manifest itself in an aggregate gender pay gap. Similarly, if a country's pregnancy and parental leave programs are inadequate and family causes women to interrupt their career path this will be reflected in the gender pay gap. Simply put, inequality in employment influences more than only equal pay for work of equal value. This pa per will examine key laws and policies aimed at promoting gender equality in employment in Sweden and Germany. It will identify and account for similarities and differences in the development and implementation of gender equality policies in these two countries. History and type of welfare regime in Sweden and Germany Throughout the 1990s in Sweden the gender pay gap remained relatively static at approximately 17.5%. According to the European Industrial Relations Observatory (EIRO) â€Å"Comparative study on gender pay equity: The case of Sweden†, â€Å"the trend is that lately, over the last ten years, with some smaller fluctuations, the wage differences between men and women are about the same. There is a decrease of the gap shown in some years, next year there is a small increase.† Throughout this period, â€Å"females earned an average of 83% of male wages.† (EIRO, â€Å"Sweden†, 2002) The statistics for Germany were much more dynamic in this period. However, they are also incomplete and difficult to work with as the period included the reunification of the two Germanies. However, they parallel Sweden with little change and a slightly higher level of the gender pay gap. (EIRO, â€Å"Germany†, 2002) Philosophically there are more profound and apparent differences between the social welfare systems in the two countries. Mandel and Shale have developed a typology for social welfare regimes that is useful in this situation. They characterise European social welfare systems as conservative, liberal or social democratic. The differences between the three are predicated on the three roles the social welfare system can play. According to Mandel and Shalev (2009), â€Å"Scandinavian social democracy is associated with patterns of intervention that exemplify all three roles: the state substitutes for Source: Mandel and Shalev, 2009. functions otherwise performed by markets or families and it does so with a distinct emphasis on ser vice provision (as opposed to income maintenance), which turns it into a massive employer.† It decommodifies and defamilializes social welfare. This is the model that Sweden exemplifies. The second country under consideration, Germany, is characterised as 'conservative' by Mandel and Shalev. â€Å"Germany, France and Spain form a second cluster which is made up of conservative countries that are less

Case analysis-Boeing Vs Airbus case, international business strategy Essay

Case analysis-Boeing Vs Airbus case, international business strategy - Essay Example It was claimed by Airbus that, â€Å"both the Boeing and the McDonnell Douglas have been benefited for years from the hidden U.S. government subsidies†. This merger was a horizontal merger between the Boeing and the McDonnell Douglas. By the term horizontal merger it can be understood that the merger is occurring between the companies that produces similar goods and services. This kind of merger basically takes place when larger companies attempt to create more efficient economies of scale (Investopedia, 2010). It is evident from the case study that the performance of the McDonnell Douglas had been very poor which would have forced it to exit from the commercial aircraft business. According to the analyst â€Å"the merger with the Boeing merely accelerated the process. Because the merger would reduce the number of players in the commercial aerospace industry from three to two, it was expected that the antitrust authorities would review the merger†. Both the Airbus and the Boeing have received under the terms of joint agreement, various government aids in order to develop the large aircraft like Airbus A380 and Boeing 787. The US had made a complaint against the loans that was granted to Airbus since Boeing had not received any such kinds of aids. According to the experts of the aviation industry, by this kind of complaint the US were actually trying to prevent the EU from granting any further launch aids to the Airbus for the development of the A350. This would also help the US manufacturer Boeing to strengthen their position in the United States. In response to the complaint made by the United States aircraft makers like the Boeing against the Airbus, the EU also filed a case against the US for unlawful subsidization of the Boeing. Therefore, this seems to be the major problem as analyzed from the case study which needs proper attention (Haak & Bruggemann, 2010). Another key

ECA Essay Example | Topics and Well Written Essays - 2250 words

ECA - Essay Example Second, she is not entitled to tax credits because she has no child. A mother with a child is entitled to tax credit even if she is working part time. 1.3 The total tax credit would increase because the working tax grows as their income dropped. Even if Magdi is working less than 30 hours per week, he is entitled to working tax credit because his father needs care. 1.4 a. Option A will bring more income into the household because the loss of income will be recovered. Furthermore, caring for his father can be done by Sara. The household will still be entitled to a working tax credit thus increasing the source of income which would include the attendance allowance given for the father that is tax free. Also, when Magdi works until the age of 65, he will not incur losses in his pension. b. Option B might bring new source of income for the household because the Magdi would be entitled to Carer’s Allowance. The Carer’s allowance can be paid to both Magdi and Sara. Carer’s allowance is designed to replace earnings that are lost through being a full-time care giver. 2.1 a. Their insurance payout does not match the full amount of their income loss because of state benefits will produce only a well below average income, thus the payout is insufficient to sustain an existing standard of living. Also, the payout is subject to inflation rates. When insurance is a level type the value of the payout income is lesser because it is affected by the inflation rate during such pay out. 2.2 a. Asymmetric information is a situation where one party knows something that another party does not. It is used to refer to information on insurance. Insurers have the information about probabilities of adverse events occurring and base their pricing decisions on those probabilities which they have worked out from their years of claims experience. Individuals, on the other

Professional Portfolio Essay Example | Topics and Well Written Essays - 500 words - 1

Professional Portfolio - Essay Example Learning is an active process, which requires patience, dedication and confidence. Teaching nursing student involves evaluation, which can serve a number of services such as providing relevant data for decision making, diagnosing problems and improving the learning outcomes. Ambitious students enter into a learning process with the willingness of being evaluated so as to give them a guarantee of how they are fairing in their career. In the same way, good teachers should be capable of putting forward the methods, which they intend to use throughout the evaluation process. I am an evaluator; I take this as one of the many methods of scrutinizing learners in this practice. Essentially, I give a learning setting of a classroom with a topic of administering oral medication to patients. Its main purpose is to encourage critical thinking and excellent communication between learners and the patients. This also ensures that learners develop cordial relationship with patients’ staff and instructors. Moreover, I evaluate the learners through oral presentation. Oral presentation entails learners being able to communicate to patients properly at all times. This contributes in building confidence and demonstrating their oral communication skills. In fact, every learner is expected to give a presentation on how to administer to patients and monitor the changes that are present in patients pertaining to their diseases. Further, the learners should be in a position to give explanation of what should be done in case patients do not respond positively to the prior medical dosage. I am a dedicated nursing educator. I am aware that nursing is a sturdy job. This means that I must portray an infinite dedication that should be imitated by the learners. I demonstrate this by evaluating the ability of the learners while he/she is recommending proper oral dosages that are forwarded to me in writing. In the writings, learners are expected to describe the procedures that

Women Fragmented Body As A Selling Tool Research Paper

Women Fragmented Body As A Selling Tool - Research Paper Example Advertising is a form of marketing communication where the elements or ingredients of communication is used to encourage, motivate, persuade and even manipulate an audience for causing some action, that is, causing sales and ensuring continuance of the action. 1 With the increasing competition and the emergence of newer entities in the market it has become extremely important to keep oneself into the glare of the public eye, the subject of the talk, constantly improve and renovate oneself and let people know about the same. This calls for the need of brilliant use of advertising and marketing skills. Advertisement in its basic form is conveying information about the existence of a particular product in the market or its availability, different features of the product, the listed price and its benefits to attract people to it. It is communication to cause sales of the product and even services. With the market becoming over crowded with products and service providers it is increasingly becoming important to get the attention of the public and maintain the same so that they do not lose their occupancy over the market. Not only that, it also aims to gain more market share and presence and increase it sales and become the unbeatable brand. 2 Advertisement is a marketing tool and, the main purpose of advertising is to grab the attention of people who are also the potential customers. 3 The thrust area of advertisements is to affect the audiences with the messages in the advertisements so that they are pursued to buy products or avail the advertised services. So, the advertisers use a number of attractive elements in the advertisements to get an instant share of the audience’s attention which later gets translated into pursuance for the sale of the product or services. 3 The robust development of technology has resulted television in every

HOW MIGHT THE HOLISTIC MODEL HELP MEET THE MENTAL HEALTH NEEDS OF Essay

HOW MIGHT THE HOLISTIC MODEL HELP MEET THE MENTAL HEALTH NEEDS OF OLDER PEOPLE - Essay Example The holistic model encourages nurses to constantly look for factors and relations that affect the complexity of health and illness (Keady & Watts 2010). Application of this model in mental health care nursing requires involvement of the whole persons’ wellbeing and the overall quality of life style with the focus of the nursing interventions directed towards restoring overall harmony with a sense of purpose and meaning in an individual’s life. The patient under nursing care is considered a co-participant in health promotion, working closely with the nurse to determine necessary and appropriate interventions over their health condition. Multidisciplinary team assessments and treatment of older people with mental health problems facilitates implementation of the holistic approach to care for and meet the complex health and social needs presented by this group of patients (Gask 2009). According to Corry (2005), the need for holistic approach in the care of people with ment al illnesses has been illustrated by a report associating poor physical care with the high rate of deaths among such people in UK. Studies have shown that people with severe mental illness are at greater risk of physical illness attributed to their lifestyle factors and mental condition. Further studies have shown that despite the UK government’s recommendations for physical health assessment among people with severe mental health problems majority of the patients lack any health history or lifestyle management plan (Corry 2005). The physical health of people with severe mental illness especially among the older people remains a major concern with evidence indicating that psychiatric patients have high rates of physical illness that go undetected contributing to increased premature deaths (Neno, Aveyard & Heath 2008). In addition, most people with mild mental illnesses are neglected, with little or no focus in helping them overcome such illness. Older people experience mental illness that is complex, enduring and debilitating and sometimes age with long-standing mental health needs. Older people with enduring mental health problems have several needs requiring professional care including the long-term effects of high doses of psychotropic medication, the erosion of a person’s social skills and ability to adhere to positive healthy life approaches, high use of alcohol and other substance abuse (Keady & Watts 2010). Other issues arising from the application of the non-holistic approach include confusion of some symptoms for aspects of mental illness, including symptoms common in old age such as anoxia, pain, constipation and weight loss. Application of the Holistic Approach or Model All the discussed needs must be addressed amicably if improved mental health and quality of life were to be realized in this group of people hence the need for the holistic approach in managing such needs. A holistic approach is able to integrate physical needs, social, environmental, economic and psychological needs in managing mental illnesses among the older people (Keady & Watts 2010). Through the holistic approach mental health nurses should focus on connecting with the older people and families in their distress, provide security, create trust and good relationship where the people can confident in finding meaning and truth about their situation. In this case, skilled,

Should the U.S. intervene in some way in Syria or should it stay out Research Paper - 1

Should the U.S. intervene in some way in Syria or should it stay out - Research Paper Example Assad of backing up Kurdish rebels with the intention of inflaming pressures between the Turkey and Kurds. American intervention could therefore contain the situation and avoid more conflicts (Yossi 56). United States’ involvement in Syria could form a fortification against terrorist groups such as the Al Qaeda. American can only achieve this by equipping and training trustworthy partners in Syria’s interior opposition. Most of these extremists have found safe havens in the non-administered spots in Syria. American move will not only assist Syria but the American too by apprehending some of these extremists and bringing them to justice (Zisser 24). Additionally, American involvement on Syria might mend associations with crucial allies like Qatar and Turkey. The prime minister of Turkey and his Qatari equivalent have condemned America for presenting only non-fatal backing to the revolt. Both approved the establishment of a no-fly area and â€Å"secure areas† for civilians in the territory of Syria yet these precautions will end the conflict (Perthes 65). Lastly, American intervention in Syria might culminate a dreadful human-rights catastrophe in Syria and halt the migration of emigrants, which is establishing a liability on bordering states. President Obama guaranteed prior this year to reinforce the government’s capacity â€Å"to predict, avoid and act to mass and genocide atrocities.† As a result, United States can avoid and stop the atrocities by positioning allies in the front-run and thereby avoid slithering down the greasy slope to ground warfare (Tucker and Roberts89). One of the cons for US intervention in Syria is the huge American’s debt. American debt is a threat its national security and economic stability. American debt has already raged over the $16 trillion dollar obligation mark. Keep in mind that United States’

Cyber War Essay Example | Topics and Well Written Essays - 250 words

Cyber War - Essay Example This is proofing to be a threat in 21st century. However, there is one serious risk of cyber war. This threat is an attack of the computer systems by the malware (Gartzke, 2012). This is because it can cripple a country infrastructure with a coordinated move. This means the primary sectors of the economy will fail to perform, and this can lead to unprecedented loss. For example, if the cyber criminals attack power plants, the whole nation could be plunged into darkness (Gartzke, 2012). This mean most of the countries can remain in a position that was there two hundred years ago. This can paralyze a country before the problem is rectified. Huge amount of resources will need to be mobilized to resolve the threat. According to my thinking, the first country to establish a large-scale cyber offensive will be South Korea. This is because the country is heavily dependent on the internet. In fact, virtually all sectors of the economy depend on the latest technological advancements. North Korea, on the other hand, has little to lose, as it is less dependent on the technology (Gartzke,

Apply Legal and Ethical Parameters to Nursing Practice Essay Example for Free

Apply Legal and Ethical Parameters to Nursing Practice Essay 1. Australian Health Practitioner Regulation National Law (The National Law 2009) has great importance on the governance of the conduct of registered and enrolled nurses. The National Law allows national boards to manage the development of health profession standards. The National Law has requirement for national boards to enterprise wide range consultation on registration standards, codes and guidelines. The National Law organise a national scheme which include registration arrangement, accreditation arrangement, complaints, conducts, health and performance arrangements, privacy and information-sharing arrangement and transitional arrangements. 2. (a). Two legislations that mandate nurses to report to nominated government authorities where elderly people and/or children in their care are at risk of harm from others are Australian Health Practitioner Regulation National Law (2009) Children and Community services amendment act 2008 (b). These acts are state act, which can vary state or territory wide in Australia. (c). These legislations make ENs aware to provide safe environment and keep away elderly people and children from any harm by reporting to nominated government. This legislation helps to reduce some professionals to be involved in some cases. It is legal requirement for ENs to report all reasonable beliefs of any risk of harm for elderly people and/or children. 3. Four domains of the National Competency Standards for Enrolled Nurse are: (a) Professional and Ethical practices: Enrolled Nurses work according to legislation, policies and procedures to demonstrate knowledge of legislation and common law, organizational policies and procedure, fulfill the duty of care, report practices that may breach legislations, polices and procedures. ENs performs in ethical way, respect the rights of individual and groups, and accept accountability and responsibility for own actions within enrolled nursing practices. (b) Critical thinking and analysis: Enrolled nurses establish critical thinking to perform enrolled  nursing practice by assessing own performance through nursing standards, by self professional development, by own care. (c) Management of care: Enrolled nurses participate to form care plans with RN through accurate data collection and report of health and functional status of individuals and groups, through identification of expected healthcare outcomes, through evaluation of progress of individuals and groups to achieve expected outcomes with RN. ENs manage nursing care of individuals and groups by implementing planned nursing care to get identified outcomes, by recognizing any change in health and functional status, report and document it accurately and on time. (d) Enabling: Enrolled nurses promote safety, security and personal integrity of individuals and groups, which include their actions of safety, create and maintain effective communication, applying strategies for promotion of self-esteem of individual and groups, actions to maintain dignity and integrity of individuals and groups. Enrolled nurses provide support and care to individuals and groups and participate with members of healthcare team to achieve effective healthcare outcomes. 4. The NMBA new Code of Ethics August 2008 define the nursing profession’s commitment to respect, promote, protect and support the fundamental rights od receiver and provider of nursing and healthcare. Its impact on practice of enrolled nurses is to: Provide quality nursing care, taking action on reasonable ground Respect the individual’s ethical values with gentleness Understand different culture and languages influence the nursing and healthcare Demonstrate the ability to reasonably and equitably provide services depends on needs, social standings, ethnicity, age, race, level of income, gender Support culture of safety because safety is everyone’s responsibility Document all information accurately, non-judgmentally and relevant to health, acre and treatment of a person and should be confidential Prevent, minimize and overcome the harmful effect of economic, social or ecological factors on health Promote and maintain the trust between nurse care receiver Perform ethically 5. The purpose of NMBA new code of Professional Conduct August 2008 for nurses is to: Specify a base to consumer, regulatory, employing and professional bodies for evaluating professional conduct of nurses Form a set of minimum national standards of conduct, nurses are supposed to support Inform the community of standards of professional conduct, it can sustain nurses in Australia References: 1. Nursing and midwifery board of Australia, 27 October 2009, consultation paper on registration standards and related matters, viewed 16 August 2014, www.ahpra.gov.au 2. Australian Health Practitioner Regulation Agency, 2010, Australian Health Practitioner Regulation Law 2009, viewed 16 August 2014, www.ahpra.gov.au 3. Australian Health Practitioner Regulation Agency, 2014, Mandatory notification, viewed 15 August 2014, www.ahpra.gov.au 4. Australian Institute of Family Studies, 8 August 2014, What is mandatory reporting?, viewed 15 August 2014, www.aifs.gov.au 5. Hughson, J, 2013, ‘Nursing: Historical, present and future perspectives’, The Tabbner’s Nursing Care (6th edition), Kesteven S., Libby Houston, Chatswood, NSW, pp. 11-12 6. Australian Nursing Midwifery Council, 2008, Codes of professional conduct and ethics for nurses and midwives in Australia, viewed 17 August 2014, http://dlb.sa.edu.au/tsftfmoodle/pluginfile.php/998/mod_resource/content/0/COMMUNICAT E_AND_WORK_EFFECTIVELY_IN_HEALTH/element_1/ANMCwebsiteversion.pdf 7. Nursing and midwifery board of Australia, 2014, Codes of Professional conduct for nurses in Australia, viewed 17 August 2014, www.nursingmidwiferyboard.gov.au 8. Nursing and midwifery board of Australia, 2014, Codes of Ethics for nurse august 2008, viewed 17 August 2014, www.nursingmidwiferyboard.gov.au

Anaemia During Pregnancy: Case Study

Anaemia During Pregnancy: Case Study ANAEMIA DURING PREGNANCY The wonder and joy ofpregnancyis matched by the bodys ability to adapt to looking after the growing baby. In addition to the mothers physiologic needs, there is the additional need to provide the building blocks for optimal growth of the baby. All this construction requires energy and oxygen as the fuel that helps drive the engine. Oxygen in the air that we breathe is delivered to the cells of the body by haemoglobin, a protein molecule found in red blood cells. When the blood lacks level of healthy red blood cells or haemoglobin it leads to a condition called anaemia. The main part of red blood cells is haemoglobin that binds to oxygen. If red blood cells is too few or the haemoglobin is abnormal or low , the cells in the body will not get enough oxygen. The body goes through significant changes when a woman is pregnant. Anaemia is a common disorder in pregnancy, which affect 20 to 60% of the pregnant women. About 20 to 30% of blood increases in the body, which increases the supply of iron and vitamins which are required in the production of haemoglobin. Most of the mothers lack adequate amount of iron during the second and third trimester of pregnancy. A mild anaemia is normal during pregnancy due to increase in the blood volume, but however a severe anaemia can put the baby at high risk of iron deficiency later in infancy. There are different types of anaemia that can develop during pregnancy such as fotal-deficiency anaemia vitamin B12, deficiency anaemia and iron deficiency anaemia. According to Cashion Alden, Perry (2009) In pregnancy, ladies need extra folate to make the red blood cells to transport oxygen to tissues throughout the body. Folate deficiency can directly contribute to certain types of birth defects. Folate-deficiency anaemia, folate which is also called folic acid, is a type of vitamin which is needed for the body to produce new cells, including healthy red blood cells. Iron-deficiency anaemia is when the body does not have enough iron to produce adequate amounts of haemoglobin, and is the most common cause of anaemia in pregnancy. To form healthy red blood cells the body needs vitamin B12 from her diet, the body would not be able to produce enough healthy red blood cells. Ladies who do not eat meat, poultry, dairy products, and eggs have a risk of vitamin B12 deficiency, which can lead to birth defects. Severe or anaemia which is untreated can lead to preterm or low-birth-weight baby, postpartum depression, baby with a serious birth defect of spine or brain, prenatal mortality or maternal death. . Some of the symptoms of anaemia during pregnancy are pale skin, lips and nail, feeling tired or weak, dizziness, shortness of breath, and rapid heartbeat. Antenatal care refers to care given to a pregnant woman from the time of conception is confirmed until the beginning of labor. Risk factors for anaemia in pregnancy can be woman pregnant with more than one child, two pregnancies close together, vomiting a lot because of morning sickness, teenager who is pregnant, not eating enough foods that are rich in iron and heavy periods before became pregnant In nursing process Assessment is the first stage in which nurse carries out a complete and holistic nursing assessment. Normal ward routine of nursing care procedures in antenatal unit at booking and important nursing focus areas is followed. Antenatal booking appointment, which provides the midwife with the valuable background information. The subjective and objective data is collected. The purpose of the visit is to bring together the woman to the maternity service. The information is shared between the mother and the midwife in- order to discuss, plan and implement care for duration of the pregnancy, the birth and postnatal period. During my attachment in antenatal clinic a mother came in for antenatal booking. Collecting her personal history, she is Mrs X, Indian married female. Her date of birth is 22th January, and is now 23 years old. , she is a high school graduate, is able to read and write and follow instructions, able to maintain eye to eye contact and is married to a 25 years old taxi driver named Mr Y. She is staying with her husband, his parents, two brother’s and a sister. They live in a wooden house near the copra mill. The mother is from Waibula but lives with relatives in Namara. Her emergency contacts were of her husband xxxxxxx and cousin sister xxxxxxx. Her family history, Mrs X mother is diabetic and her sister had twins. Mothers medical history was occasionally complains of migraine, and heavy menstrual bleeding. The husband and his elder brother are driving taxi and also they do a casual job in the timber mill. Mrs last normal menstrual period was on 25th of September 2012, her expec ted date of delivery is on the 7th of January 2013. She missed her period for two months. There was no gynaecological history present. Starting with her examinations, the height is 6 feet and 4 inches (1.65m) and is 66 kilograms. The urine test was normal, blood pressure was 80/40mmHg, temperature of 37.5 °C,pulse rate: 114 bpm, respiratory rate: 28 bpm skin: (+) pallor, (-) jaundice, (-) cyanosis, head:, EENT: pale palpebral conjunctiva, negative cervical lymp adenpathy chest, lungs: symmetrical chest expansion, (-) retractions heart: adynamic precordium, tachycardia, (-) thrills, (-) murmur abdomen: globular, soft, normal and active bowel sounds, non-tender extremities: pale nail beds, cold upper and lower extremities (-) cyanosis, weak peripheral pulsesneurological: No found neurological deficits rectal exam: No haemorrhoids, no fissures, no masses, palpated, no tenderness, intact rectal vault, good sphincter tone. In the blood test, the full blood count was done and was low an d proven to be anaemic. In order to ensure that the outcome of the pregnancy is the best for mother and baby, a routine is undertaken which is embraced by the term â€Å" antenatal care†. Fraser and Copper (2009) stated â€Å" the aims of antenatal care is to monitor the progress of pregnancy to .maternal and fetal health, developing a partnership with the woman, providing a holistic approach to the woman’s care that meets her individual needs, promoting an awareness of her public health issues for the woman and her family, exchanging information with the woman and her family, enabling them to make informed choices about pregnancy and birth, being an advocate for the woman and her family during her pregnancy, supporting her right to choose care appropriate for her own needs and those of her family, recognizing complications of pregnancy and appropriately referring woman to the obstetric team or relevant health professionals or other organizations, facilitating the wom an and her family in preparing to meet the demands of birth, making a birth plan, facilitating the woman to make an informed choice about methods of feeding and giving appropriate and sensitive advice to support her decision and offering parenthood education within a planned programme or an individual basis†.(P.g 265). During booking the mothers blood was sent in the laboratory for tests. The haemoglobin level 12g/dL or if it is the haematocrit less than 30% in a pregnant woman. Then it proves that the woman is anaemic. Mrs X haemoglobin level was 8.7g/dL and hemocrit was 25% , so it proved that she is anaemic. It is the risk to the mother and the fetus., So the nursing problem was diagnosed to Mrs X that she was suffering from Iron Deficiency Anaemia. Fraser et al. (2009) stated â€Å" iron deficiency anaemia is the most common hematologic disorder in pregnancy, it affects approximately 15% to 25% of pregnant woman, depending on the ethnic and socioeconomic groups being studied†.(P.g 872). After the diagnosis of iron deficiency anaemia Mrs X was referred to the doctor. The body produces more blood to support the growth of the body. The existence of a hematologic abnormally increases the pregnant women’s risk for developing more complication such as infection or preterm delivery If the mother not getting enough iron or certain other nutrients, the body might not be able to produce the amount of red blood cells it needs to make this additional blood. Taylor, Lillies, Lemone Lynn (2011) stated â€Å" carbohydrates, protein and fats are potential sources of energy for the body†.(P.g 1158). Mrs X presented with symptoms of pale skin, lips and nails, feeling tired or weak, dizziness, shortness of breath, rapid heart rate and trouble concentrating. It is very important to assess the wellbeing of the fetus. This was done by checking the fetal movement and listening to the fetal heart sound using a fetal cardio graph machine. The bloods were performed to see the changes that may indicate worsening of anaemia. The nurses has its own independent role scope of practice to ensure that the mother and fetus are healthy. The nurses role in managing the pregnant woman in this case of Mrs X are as follows. Nurses can be councillor, collaborator and advocator. The role of the nurse at first step will be taking or monitoring vital signs of the mother and thefetal heart rate. To assess the fetal heart rate, fetal heart sound and fetal kick count was monitored. Urine check is another important role of nurse in monitoring an anaemic mother. The mother will be asked to bring along a urine sample for glucose and protein level. In early pregnancy if protein level will be high it can be sign of problems including urinary tract infection, a kidney disorder , high blood pressure or diabetes. If in later pregnancy protein of high level is found is sign of pre-eclampsia. Taking of height and weight measurements is another role of a nurse, also to work out body mass index. Potter, Perry, Stockert Hill (2013) st ated â€Å" body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships†.(P.g 56). Since the nurse knows the diagnosis of Mrs Mrs Xshe can advise on what kind of foods to consume .She was advised to take foods that are rich in iron examples are red meat, egg yolks, dark leafy vegetables, dried fruit, iron-enriched cereals, grains, chicken giblets, beans, lentils, and liver. Establishment of quiet and peaceful environment to promote rest. During her hospitalization Mrs X was served with full diet. The nurse also taught to the woman on correct positioning while resting.The nurses also did health education with the husband on health. Nurses need to follow the physicians orders in giving the prescribed medications on time.They also advised on personal hygiene. In antenatal care the nurse needs to collaborate with other health care professionals, such as dietician, the obstetric, doctor, haematologists and physiotherapist. To enablepeople to make informed and practical choices about food and lifestyle in health and disease, the role of a dietician comes in, dietetics is the interpretation and communication of nutrition science. The role of a dietician was to prepare a food guideline for Mrs X. Obstetric team works with patients who are wanting to become to become pregnant, is pregnant or have recently delivered. The obstetricnurse have plenty roles in managing an anaemic mother. Mrs Narayan was admitted, reviewed, history taken, vaginal examination, fetal heart tones, and duration and intensity of contractions was done by an obstetric nurse. Paediatrician doctoradvised on healthy and successful delivery of Mrs Narayan, also advised on diet and medication compliance. Paediatrician doctor also took blood and urine test. The roleof midwife is to provide pregnancy care to woman during pregnancy and during birth. The midwife took Mrs X medical history and explained in detail the limitations and risks associated with pregnancy while being anaemic. The midwifealso checked urine for protein and heart beats for the developing baby. Health education was also provided by the midwife. The doctor was also responsible to prescribe medications, examination and to consider delivery if the condition of mother gets worse and fetus gets distressed. The physiotherapist taught Mrs X on exercise that was helpful to her. There are rationales behind the nurses independent roles in ensuring the well-being of the mother and the fetus. As stated earlier monitoring of vital signs, it is very important because to see if Mrs X condition is stable or not. Also same for the fetal heart rate and fetal sounds to see if everything is normal or not. Monitoring fetal heart rate and fetal sound to ensure that the fetus is not distressed. Urine checkis also important factor, it is done by the nurses to see if the glucose and protein level is normal or requires attention. Taking of height and weight is also important to see if mother is healthy and gaining weight since she is pregnant.Also to calculate the body mass index of the mother. The nurse providing health education on her diet, encouraging her to take iron rich foods to prevent or stop Mrs X from getting anaemic. The nurse administers medication as prescribed by the doctors to make Mrs X to improve on her health.Personal hygiene is really important because th e way mother keeps her self affects or reflects the fetus as well. There are rationales behind the professionals collaborative roles in establishing or giving quality care to the pregnant mother. Taking of history from the mother is to know whether she had any past medical problems, such as gynaecological issues or any surgeries that can hinder her present pregnancy. Doctors or paediatricians take samples of blood to see if mother is seriously anaemic or requires attention, or to see if there could be any complications.The rationale of doctors doing vaginal examination is to see cervical dilation or any complications which can arise. Counselling by the doctors of having proper diet or dieticians, to improve the condition of the mother and avoiding complications. Obstetric team was to ensure that if emergency develops there could be urgent need to conduct delivery in caesarean section, because they have knowledge on when and how to conduct delivery in emergency situation. Doctors presenting medication to increase iron level in the blood. Physiotherap ist needed to educate mother on exercise to help her in delivery. During the end of the antenatal clinic, the strengths and weakness of Mrs X was found and identified, it was recorded in evaluation. Mrs X was adjusted to what the plan was ruled out for her. Her strengths were that she followed her diet to what the dieticians planned for her. The health education was really effective to her and her husband supported on her diet and growing fetus. The family support was also there and she was in happy environment, free of fear and anxiety. Mrs X also took her tablets on time and gained weight. Another blood test was done and was found out that her haemoglobin level was normal. The benefitsof maternal iron supplementation on these outcomes are unclear, even for woman who develop anaemia during pregnancy. There is vivid evidence that maternal iron deficiencyanaemia increases the risk of preterm delivery and low birth weight. Iron supplementsimprove the iron status of the mother during pregnancy and during the postpartum period, even in woman who enter pregnancy with reasonable iron stores. Through my point of view, the mass of evidence supports the practice of routine iron supplementation during pregnancy, even though iron is most common and important for woman who have anaemia. ( Approx: 2443 words.) Reference Potter, P, A., Perry, A, G., Stockert, P, A., Hill, A, M. (2013). Fundamentals Of Nursing (8th ed.). United States Of America: Mosby. Fraser, D, M., Copper, M, A. (2009). Myles: Textbook for midwives (15th ed.). Edinburgh: Churchill Livingstone. Lowdermilk, D, L., Perry, S, E., Cashion, K., Alden, K, R. (2012). Maternity Women’s Health Care ( 10th ed.). United States Of America: Mosby. Taylor, C, R., Lillis, C., Lemone, P., Lynn, P. (2011). Fundammentals Of Nursing: The art and science of nursing care (7th ed.). Philadelphia: Lippincott. Reeder, S, J., Martin, L, L., Martin, L, L. (1997). Maternity Nursing: Family, newborns, and women’s health care (18th ed.). Philadelphia: Lippincott. 1

Consequences of child abuse and neglect

Consequences of child abuse and neglect Introduction Child abuse and neglect are an unfortunate reality for many children in our community. The past thirty years have witnessed a growth in our awareness of and attention to the problems faced by children exposed to violence in their homes. The consequences of maltreatment can be devastating. For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive, and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attentional problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations all the way to extraordinarily violent behaviors. Thus, the consequences of abuse and neglect affect the victims themselves and the society in which they live. REVIEW OF DEFINITIONS A 1989 conference convened by the National Institute of Child Health and Human Development recommended that maltreatment be defined as behavior towards another person, which (a) is outside the norms of conduct, and (b) entails a substantial risk of causing physical or emotional harm. Behaviors included will consist of actions and omissions, ones that are intentional and ones that are unintentional (Christoffel et al., 1992). The term child maltreatment refers to a broad range of behaviors that involve risk for the child. Four general categories of child maltreatment are now generally recognized: (1) physical abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category, in turn, covers a range of behaviors. Physical abuse includes scalding, beatings with an object, severe physical punishment, and a rare form of the abuse called Munchausen by proxy, wherein an adult will feign or induce illness in a child in order to attract medical attention and support. Sexual abuse includes incest, sexual assault by a relative or stranger, fondling of genital areas, exposure to indecent acts, sexual rituals, or involvement in child pornography. Child neglect is the presence of certain deficiencies in caretaker obligations (usually the parent, although neglect can be found in residential centers or foster care homes) that harm the childs psychological and/or physical health. Child neglect covers a range of behaviors including educational, supervisory, medical, physical, and emotional neglect, and abandonment, often complicated by cultural and contextual factors. Several authors (Mrazek and Mrazek, 1985; Zuravin, 1991) have noted the relative lack of attention to definitional issues of child neglect, particularly given its greater reported prevalence (NCCAN, 1981, 1988b; Wolock and Horowitz, 1984). Emotional maltreatment, a recently recognized form of child victimization, includes such acts as verbal abuse and belittlement, symbolic acts designed to terror ize a child, and lack of nurturance or emotional availability by caregivers. Effects of child abuse and neglect Physical Health Consequence The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. According to the National Survey of Child and Adolescent Well-Being (NSCAW), more than one-quarter of children who had been in foster care for longer than 12 months had some lasting or recurring health problem (Administration for Children and Families, Office of Planning, Research and Evaluation [ACF/ OPRE], 2004a). Below are some outcomes researchers have identified: Shaken baby syndrome: Shaking a baby is a common form of child abuse. The injuries caused by shaking a baby may not be immediately noticeable and may include bleeding in the eye or brain, damage to the spinal cord and neck, and rib or bone fractures (National Institute of Neurological Disorders and Stroke, 2007). Impaired brain development: Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, De Bellis, 2006). NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/ OPRE, 2004a). Poor physical health: Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, Carnes, 2007). Psychological Consequence The immediate emotional effects of abuse and neglectà ¢Ãƒ ¢Ã¢â‚¬Å¡Ã‚ ¬isolation, fear, and an inability to trustà ¢Ãƒ ¢Ã¢â‚¬Å¡Ã‚ ¬can translate into lifelong consequences, including low self-esteem, depression, and relationship difficulties. Researchers have identified links between child abuse and neglect and the following: Difficulties during infancy: Depression and withdrawal symptoms were common among children as young as 3 who experienced emotional, physical, or environmental neglect (Dubowitz, Papas, Black, Starr, 2002). Poor mental and emotional health: In one long-term study, as many as 80 percent of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21. These young adults exhibited many problems, including depression, anxiety, eating disorders, and suicide attempts (Silverman, Reinherz, Giaconia, 1996). Other psychological and emotional conditions associated with abuse and neglect include panic disorder, dissociative disorders, attention-deficit/ hyperactivity disorder, depression, anger, posttraumatic stress disorder, and reactive attachment disorder (Teicher, 2000; De Bellis Thomas, 2003; Springer, Sheridan, Kuo, Carnes, 2007). Cognitive difficulties: NSCAW found that children placed in out-of-home care due to abuse or neglect tended to score lower than the general population on measures of cognitive capacity, language development, and academic achievement (U.S. Department of Health and Human Services, 2003). A 1999 LONGSCAN study also found a relationship between substantiated child maltreatment and poor academic performance and classroom functioning for school-age children (Zolotor, Kotch, Dufort, Winsor, Catellier, 1999). Social difficulties: Children who experience rejection or neglect are more likely to develop antisocial traits as they grow up. Parental neglect is also associated with borderline personality disorders and violent behavior (Schore, 2003). Behavioural Consequences Not all victims of child abuse and neglect will experience behavioral consequences. However, behavioral problems appear to be more likely among this group, even at a young age. An NSCAW survey of children ages 3 to 5 in foster care found these children displayed clinical or borderline levels of behavioral problems at a rate more than twice that of the general population (ACF, 2004b). Later in life, child abuse and neglect appear to make the following more likely: Difficulties during adolescence: Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, drug use, and mental health problems (Kelley, Thornberry, Smith, 1997). Other studies suggest that abused or neglected children are more likely to engage in sexual risk-taking as they reach adolescence, thereby increasing their chances of contracting a sexually transmitted disease (Johnson, Rew, Sternglanz, 2006). Juvenile delinquency and adult criminality: According to a National Institute of Justice study, abused and neglected children were 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime (juvenile or adult) (English, Widom, Brandford, 2004). Alcohol and other drug abuse: Research consistently reflects an increased likelihood that abused and neglected children will smoke cigarettes, abuse alcohol, or take illicit drugs during their lifetime (Dube et al., 2001). According to a report from the National Institute on Drug Abuse, as many as two-thirds of people in drug treatment programs reported being abused as children (Swan, 1998). Abusive behavior: Abusive parents often have experienced abuse during their own childhoods. It is estimated approximately one-third of abused and neglected children will eventually victimize their own children. Societal Consequences While child abuse and neglect almost always occur within the family, the impact does not end there. Society as a whole pays a price for child abuse and neglect, in terms of both direct and indirect costs. Direct costs: Direct costs include those associated with maintaining a child welfare system to investigate and respond to allegations of child abuse and neglect, as well as expenditures by the judicial, law enforcement, health, and mental health systems. Indirect costs: Indirect costs represent the long-term economic consequences of child abuse and neglect. These include costs associated with juvenile and adult criminal activity, mental illness, substance abuse, and domestic violence. They can also include loss of productivity due to unemployment and underemployment, the cost of special education services, and increased use of the health care system. Possible Treatment Strategies Descriptions of treatment for child sexual abuse, physical abuse, and neglect have been reported separately within the literature, with much more attention paid to treatment of child sexual abuse. In fact, there are relatively few studies or reports of individual treatment of the physically abused or neglected child. In practice, however, treatment programs often address individual needs of children. The emphasis here is cognitive behavioral treatments, as these have shown the greatest effects in controlled studies. General Issues for Treatment First and foremost, it is important that the child be safe from potential harm from the offender as well as from non-believing or unsupportive family members. In addition to ethical issues of treating a child within an unsafe environment, treatment of abuse related problems is not likely to be effective if the child is living in such conditions. The targets for treatment are determined to a large degree by the childs presenting symptoms and are defined following the initial assessment. There are, however, certain overriding goals that should guide the treatment process. Treatment should be directive and focused on the abuse or trauma itself. Treatment approaches: Help and encourage the child to talk and think about the abuse/neglect without embarrassment or significant anxiety. Help the child to modulate and express feelings about the abuse; Reduce the intensity and frequency of behavioral and emotional symptoms; Clarify and change distorted, inaccurate, or unhealthy thinking patterns that might negatively affect the childs view of self and others; Help the child develop healthier attachments; Strengthen the childs coping skills Enhance social skills, and Educate the child regarding self-protective strategies. An additional goal, accomplished specifically through group therapy is to reduce the childs sense of isolation or stigma through exposure to other victims of abuse. Group treatment for victims of child physical abuse can have positive effects but may also be associated with increased behavior problems. Therefore the therapist should be cautious and monitor group participants behavior closely (Kolko Swenson, 2002). Treatment strategies Strategies for treating the abused child are varied and are used as appropriate to the childs presenting problems. Recommended treatment approaches include (Finkelhor Berliner, 1995): 1) cognitive-behavioral strategies, 2) graduated exposure to aspects of the abusive experience, 3) relaxation training , 4) education regarding abuse process and effects of abuse, 5) skills training, 6) supportive strategies teaching self-protective strategies, 7) behavioral strategies/parent training. Strategies for treating abuse victims which have received some scientific support, have been those derived from a cognitive behavioral perspective and which focus on the abuse itself. Cognitive behavioral strategies typically address the childs thinking patterns, affective response, and behavioral reactions to the abuse. In particular, the childs attributions of blame and responsibility for the abuse should be addressed. That is, the child should be helped to recognize that it is adults rather than children who are responsible for healthy parent-child interactions (Finkelhor Berliner, 1995). Gradual exposure or discussion of abuse experiences helps to reduce the childs anxiety and embarrassment and provides opportunities to modify inaccurate or self-defeating thinking processes. Relaxation training further addresses the childs fear or anxiety reaction to abuse-related cues and can facilitate more effective affect regulation. Educational approaches facilitate clarification of misperc eptions developed in response to the abuse. Skills training are used to teach the child coping strategies to manage negative emotions and to improve social/interpersonal functioning. Supportive techniques also are required, as the child may be coping with non-supportive family members, upcoming court proceedings, and/or negative reactions from peers. Education in the use of self-protective strategies is important for minimizing the likelihood that the child will be abused/neglected again (Finkelhor Berliner, 1995). It is important to establish a safety plan within the home, delineate danger cues, and identify support persons in the childs environment to decrease the secrecy within previously abusive/neglectful families. This, in turn, is expected to minimize the risk of repeated abuse. Age-related issues The treatment approach should be appropriate to the age of the child. For example, a four year old child should not be expected to come into a therapist or counselors office, sit on a couch, and recount the details of her abuse. The therapist can utilize a variety of play techniques to encourage the young child to communicate about his or her abuse. Many cognitive behavioral strategies which are used with adolescents and adults can be modified or simplified for use with young children (Kolko Swenson, 2002). For example, there are numerous scripts for relaxation training which are humorous and which engage the child in the therapeutic process. Puppets and drawings are useful as well for helping children to tell of their experiences, learn strategies for coping with negative emotions, and behaving in a more organized and directed manner. In contrast, older children and adolescents are more able to directly communicate their thoughts and feelings about their abuse experiences. It is recommended, however, that the therapist be flexible in method of approach. Drawings, therapeutic stories, and therapeutic games can be very helpful for engaging children of all ages. Treatment duration There are no clear guidelines regarding the length of treatment for the abused or neglected child, although most studies of treatment effectiveness have examined short-term interventions. Clinical experience suggests that while some children can resolve their negative reactions to the abuse in a relatively brief period (i.e., 12 16 sessions), many will require more extended treatment. Typically, treatment length will be determined by the nature of the childs social, behavioral, or emotional difficulties. That is, the child who is experiencing a wide array of problems of a serious nature is likely to require more intensive treatment over a long period of time. In addition, the quality of support that the child is receiving from the non-offending caregiver or other family members will affect treatment length. That is, child problems are typically more significant if there is no support coming from the non-offending caregiver, and, therefore, treatment of the child whose non-offending parent is disbelieving or non-supportive is likely to be more extensive than that of a child who has the support of a non-offending parent. Additional treatment approaches Family involvement in treatment Children should not be treated in isolation of intervention with their family and/or current living situation. Thus, many in the field recognize the importance of incorporating family members, particularly parents or primary caregivers, into treatment addressing abuse and neglect (Kolko Swenson, 2002). The goal of family work is to reduce the risk of recurring abuse, increase safety, and promote healthy growth and development of all family members. Family approaches address the needs of all family members while also targeting the interactions between them. However, it is difficult to specify the precise structure of therapeutic work addressing family issues. The specific approach with the family will vary; depending upon the childs living context and the level of acknowledgement of abuse by offender(s) and non-offending caregiver(s). For example, a child who has been placed in foster care due to parent-child abuse and lack of a supportive non-offending caregiver will be addressing d ifferent issues than the child who is receiving support from a non-offending caregiver and/or whose abusive parent is acknowledging abuse and is committed to treatment. Family work is not indicated if the child is in out-of-home placement and there are no plans for reunification. Treatment involving the entire family and that has as a goal family reunification is generally of a much longer duration than individual treatment of the child. Initial stages involve the child, offender, and non-offending caregiver in individual treatment, allowing members to first address individual issues related to the development and outcomes of the abuse. In addition, marital work is recommended to address relational issues between the childs caregivers prior to any reunification efforts. If early work with caregivers is successful, family therapy may ensue. The clarification session can serve as the bridge between each family members individual treatment and treatment addressing the entire familys needs. Therapeutic interventions with caregivers typically begin with individual sessions addressing the abuse itself, as well as the specific needs of family members. These stages of treatment encourage assumption of responsibility by the offender and non-offending caregiver(s). An alleged perpetrator who is denying having abused the child or a non-offending parent who does not believe that abuse has occurred cannot fully benefit from abuse-specific treatment. Therefore, initial treatment efforts focus on reducing denial. If such efforts fail, family treatment is contraindicated. If the offender is acknowledging having abused and/or neglected the child, then he or she can engage in abuse-specific treatment that addresses faulty thinking patterns, behavioral actions, emotional responses, and physiologic reactions. Sexual abuse offenders will be targeting their sexual arousal to children, thought patterns which allow them to justify perpetrating sexual abuse, and examining the behavioral repertoire that lead up to abuse. Physical abuse offenders will learn strategies for managing anger, parenting skills, and non-physical means of discipline. Caregivers who are neglectful will receive assistance in securing basic goods and resources, will learn parenting strategies and be taught skills which facilitate independent management of the children and familys needs. In the treatment of all forms of abuse it is important to address attributions of blame. Invariably child abuse/neglect offenders minimize their own responsibility for the abuse/neglect and project blame on other family members, most often the victim. The abuse clarification process (Lipovsky et al., 1998), which addresses such attributions, should be included in treatment if at all possible. The abuse clarification involves an acknowledging offender who has proceeded through treatment to a sufficient degree to be able to clarify the nature of the abuse, assume responsibility for the abuse, demonstrate empathy for the childs responses to the abuse, and begin to participate in the development of a family safety plan. The abuse clarification process is addressed in the offenders individual or group treatment and is ongoing, often for many months before an abuse clarification session is possible. The abuse clarification session provides the opportunity for the offender to read a letter written to the child victim that focuses on the offenders assumption of responsibility, empathy for the child, and commitment to developing the family safety plan. This session is likely to occur some months after the abuse are disclosed, allowing the offender sufficient opportunity to engage in and progress in his/her own treatment. Ideally, at least one supportive adult should be included in the treatment process. Several programs around the country have targeted non-caregivers parents in their approach to treating child sexual abuse and have found success with such an approach.16, 32, 50 Treatment with non-offending caregivers also must also be built upon a foundation of acknowledgement that abuse has occurred. In most cases, where non-offending caregivers believe and support their child, family work addresses the caregivers individual needs. Early treatment strategies must address denial if it is present. Treatment of the non-offending caregiver(s) addresses his/her emotional responses to the abuse and individual mental health needs. In addition, treatment includes focus on the caregivers responses to the childs abuse, education regarding the childs symptoms and provides assistance for developing strategies for reducing these symptoms. It is recommended that the non-offending parent be involved in an abuse protection clarification (Wilson Ralston, 1995). This process is similar to the abuse clarification conducted with the offender. The protection clarification involves clarification of the abuse, commitment to protection of the child, and participation in the development of a family safety plan. The protection clarification may be initiated relatively early in treatment, especially if the non-offending parent believes and supports the child from the time of disclosure. Long-term family resolution of parent-child abuse is a life-long process and involves changing many aspects of family functioning. Some type of resolution must occur in all cases, regardless of whether the child or offender has been removed from the home. Resolution may take the form of helping a child adjust to permanent foster care and cope with a non-supportive family or may involve reunification of the family following the successful completion of individual/group treatment, the clarification process, and family therapy which addresses a safety plan, alteration of family members rigid patterns of thinking and behaving (Saunders Meinig, 2000). Home-Based Services and Family Preservation Services Home-based services and family preservation services address the overall needs of families, include both children and parents, and focus directly on contextual factors, such as poverty, single parenthood, and marital discord, that increase stress, weaken families, and elicit aggressive behavior (Kolko, in press). These programs target functional relationships among diverse individual, family, and systemic problems by combining traditional social work with various therapeutic counseling approaches. The use of home-based services has been advocated in response to the multiple problems found among abusive and neglectful families, difficulties in providing services in a traditional format, and interests in reducing the number of children placed in foster care. The breadth of potential family dysfunction has encouraged hands-on approaches that address risk factors at multiple levels of the family system, such as financial problems, disruption, social isolation, and behavioral deviance (Frankel, 1988). Self-Help Services for Abusive Adults Self-help support and treatment programs are based on the premise that individuals can benefit from learning about the victimization experiences of others. These programs have attracted popular support in a wide range of health services, including the treatment of alcoholism, weight loss, and rape counseling programs, and they have also been applied in the treatment of both physically and sexually abusive adults.. A self-help component has also been integrated into treatment programs for intra-familial sexual abuse (Giaretto, 1982). Parental Enhancement Most parental enhancement programs focus on training abusive parents in child management (e.g., effective discipline), childrearing (e.g., infant stimulation), and self-control skills (e.g., anger control). Programs for neglectful parents typically focus on areas such as nutrition, homemaking, and child care. Parental enhancement programs may help some families who experience child management problems when a sexually abusive father is removed from the home. In these cases, child management skills help develop positive child- parent interaction in sexually abusive families. The efficacy of parent training approaches for physically abusive parents has been supported by various single-case studies, one study using repeated measures, and group design studies (Azar and Twentyman, 1984; Crimmins et al., 1984; Gilbert, 1976; Jeffrey, 1976; Reid et al., 1981; Szykula and Fleischman, 1985; Wolfe et al., 1981a,b, 1982). Studies of multiple approaches and diverse populations have provided consistent evidence that parents can acquire behavioral skills and use them in interactions with their children, at least in clinical settings (Golub et al., 1987). Some evidence suggests that training has reduced parental distress or symptomatology and, in some instances, improved child functioning (Wolfe et al., 1988) and reduced the likelihood of child placement (Szykula and Fleischman, 1985). Efforts to expand the scope of parental enhancement programs have fostered attention to parents cognitive-attributional and affective repertoires (see Azar and Siegel, 1990). Therapeuti c directions highlight the need to incorporate diverse skills and to evaluate the effectiveness of individual approaches (see Azar and Wolfe,1989). Psychopharmacologic treatment for child victims Medications may be used with child victims of abuse and neglect who are experiencing post-traumatic stress disorder (PTSD). A number of medications may be of use, though the state of our knowledge about which are most appropriate for use in children is limited. Some have recommended that the use of medication may be reserved for those children who do not show improvement with cognitive-behavioral treatments for PTSD. Children experiencing other types of behavioral or emotional difficulties, including depression, anxiety, or attentional problems also can benefit from pharmacologic treatment. In all cases, the choice of medications is determined by psychiatrist through a careful assessment. Family Income and Supplemental Benefits The relationship of poverty to child maltreatment, specifically child neglect, is thought to be significant. Several government programs designed to alleviate or mitigate the effects of poverty on children are often part of a comprehensive set of services for low-income, maltreating families. Such programs include Social Security supplemental income programs, Aid to Families with Dependent Children (AFDC), Women with Infants and Children food supplement program (WIC), Head Start, rent subsidy programs, and school lunch programs, among others. Gil (1970) has stated that almost 60 percent of families reported for incidents of abuse and neglect received aid from public assistance agencies during or prior to the study year. However, while national and local child welfare programs designed to improve the well-being of all poor families may provide food, shelter, and other necessary resources, for children in households characterized by neglect or abuse, the relationship between income support, material assistance, and the subsequent reduction of maltreatment has not been systematically addressed. CONCLUSIONS Medical, psychological, social, and legal interventions in child maltreatment cases are based on assumptions that such interventions can reduce the negative physical, behavioral, and psychological consequences of child abuse and neglect, foster attitudes and behaviors that improve the quality of parent-child interactions and limit or eradicate recurrences of maltreatment. Interventions have been developed in response to public, professional, legal, and budgetary pressures that often have competing and sometimes contradictory policies and objectives. Some intervention services focus on protecting the child or protecting the community; others focus on providing individual treatment for the child, the offender, or both; others emphasize developing family coping strategies and improving skills in parent-child interactions. Assumptions about the severity of selected risk factors, the adequacy of caretaking behaviors, the impact of abuse, and the steps necessary to prevent abuse or neglect from recurring may vary given the goals and context of the intervention. Little is known about the character and effects of existing interventions in treating different forms of child maltreatment. No comprehensive inventory of treatment interventions currently exists, and we lack basic descriptive and evaluative information regarding key factors that influence the delivery and outcomes of treatment for victims and offenders at different developmental stages and in different environmental contexts. A coherent base of research information on the effectiveness of treatment is not available at this time to guide the decisions of case workers, probation officers, health professionals, family counselors, and judges. Investigations of child maltreatment reports often influence the development and availability of other professional services, including medical examinations, counseling, evaluation of risk factors, and substantiation of complaints. References Administration for Children and Families, Office of Planning, Research and Evaluation. (2004a). Who are the children in foster care? NSCAW Research Brief No. 1. Retrieved August 9, 2007, from the National Data Archive on Child Abuse and Neglect website: www.ndacan. cornell.edu/NDACAN/Datasets/Related_Docs/NSCAW_Research_Brief_1.pdf A