The Diversity and Commonality of Cells. Cells come in an amazing variety of sizes and shapes d_c01_ Fundamentals of Electric Circuits (5th ed). John Murtagh's General Practice, 6th Edition () [PDF]. John Murtagh's General Practice, 6th Edition () [PDF]. 26 MB PDF. John Murtagh, Jill Rosenblatt, Justin Coleman, Clare Murtagh Part 1: The basis of general practice. Part 2: Diagnostic perspective in general practice.
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GENERAL PRACTICE 6E. **AUSTRALIAN AUTHOR**. John Murtagh's General Practice 6th Edition is the book for all GPs, registrar and student GPs. This text is . This tried-and-tested resource provides GPs general practice nurses registrars EBOOK JOHN MURTAGH'S PATIENT EDUCATION 7E (PDF). Murtagh's Practice Tips 6e John Murtagh AM MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG Emeritus Professor in General Practice, School of Primary Health .
In the same year he was named as one of the most influential people in general practice by the publication Australian Doctor. John Murtagh was awarded the inaugural David de Kretser medal from Monash University for his exceptional contribution to the Faculty of Medicine, Nursing and Health Sciences over a significant period of time.
Members of the Royal Australian College of General Practitioners may know that the honour of the namesake of the College library was bestowed upon him.
Today John Murtagh continues to enjoy active participation with the diverse spectrum of general practitioners-whether they are students or experienced practitioners, rural- or urban-based, local or international medical graduates, clinicians or researchers.
His vast experience with all of these groups has provided him with tremendous insights into their needs, which is reflected in the culminated experience and wisdom of John Murtagh's General Practice. Following terms as a resident medical officer she entered rural practice in Neerim South, Victoria, in partnership with her husband John Murtagh. Her special interests were obstetrics, paediatrics and anaesthetics.
Jill has also had a special interest in Indigenous culture and health since she lived at Koonibba Mission in South Australia, where her father was Superintendent. After leaving rural life she came to Melbourne and joined the Ashwood Medical Group, where she practised comprehensive general medicine, and care of the elderly in particular.
Jill Rosenblatt brings a wealth of diverse experience to the compilation of this textbook. This is based on 50 years of experience in rural and metropolitan general practice. She was awarded a life membership of the Royal Australian College of General Practitioners in and a Distinguished Service award of the College in Soon after graduating, Justin began writing for the GP newspaper Medical Observer and hasn't stopped since.
He even wrote 40 humorous columns until the editors lost their sense of humour. Justin is a prolific writer for medical and non-medical readerships; he has published well over 1, medical articles in around 50 different newspapers, magazines, books and journals. For five years he served as President of the Australasian Medical Writers Association and he regularly runs writing workshops for medical writers and academics. Since completing a Master of Public Health UQ , first class hons , Justin has dedicated much of his career to educating other GPs about how to improve various aspects of medical practice.
His interests include evidence-based medicine, the rational use of medical tests and treatments, and dealing with uncertainty during a GP consultation.
Molluscum contagiosum Sports injuries: Sleep problems: Practice Tips. In the same year. University of Notre Dame. In he was awarded the Member of the Order of Australia for services to medicine.
Following a comprehensive postgraduate training program. His vast experience with all of these groups has provided him with tremendous insights into their needs. Dr Jill Rosenblatt. Graduate School of Medicine. Western Australia Guest Professor. Nursing and Health Sciences over a significant period of time. School of Primary Health Care.
He combines these positions with part-time general practice. Today John Murtagh continues to enjoy active participation with the diverse spectrum of general practitioners—whether they are students or experienced practitioners.
University of Melbourne. He was appointed to a professorial chair in Community Medicine at Box Hill Hospital in and subsequently as chairman of the extended department and Emeritus Professor of General Practice in until retirement from this position in Beijing John Murtagh was a science master teaching chemistry. Adjunct Clinical Professor. University of Notre Dame and Professorial Fellow. Melbourne Professorial Fellow. University of Melbourne Adjunct Clinical Professor. Monash University.
Peking University Health Science Centre. Department of General Practice. People are more interested than ever before in the cause and management of their problems. These trends reinforce the perceived value of this form of health education.
The other impetus for this project came from the members of the Monash University Department of Community Medicine and General Practice. Such practitioners are invited to use this information for a variety of purposes. We have not simply featured illnesses.
The author has produced patient education information to fit onto one sheet. It is now a much requested inclusion in computer programs for doctors and is blossoming on the Internet. Experience has shown that better understanding of a problem or potential health problem leads to better cooperation and compliance with treatment.
Following a rather indifferent response to the initial production of material in AFP. Apart from providing valuable learning material for the students. The catalyst for the initial production of this material came from two sources. The author believes that the subject matter in this book covers common everyday problems encountered by doctors and hopes that the dissemination of this information will benefit both health-care providers and people who are interested in their health.
Preface In modern medicine patient education has become a very important and expected method of patient care. These sheets should have considerable value in undergraduate courses for doctors.
The strategy was to present information on the most common problems presenting to general practitioners. The material presented in this book is not intended to be used as an alternative to the verbal explanations given by the doctor during the consultation but as complementary information to be taken home. Patient education sheets have been a feature of monthly publications of AFP since Cynthia Welling Incontinence of urine. Jenny Barry Dysmenorrhoea. Jenny Gunn and Pat Phillips Diabetes: Denise Findlay Breast self-examination.
Westmead Hospital. John Goldsmid Lice: Kris Berntsen. Robin Beattie Stress: Richard Williams Exercises for your knee. Don Lewis. Lisa Amir Establishing breastfeeding. Individual contributions. Other educational organisations that have provided ideas and material are the Paediatric Health Education Unit. Rod Kruger Ear: Alison Walsh. Leanne Rowe Prostate: Robin Marks. Exercises for your shoulder.
Michael Axtens and Lou Sanderson Common cold. Jim McDonald Haemorrhoids. United Kingdom. Jenny Green and Caroline Menara for typing the manuscript. Ian McKenzie Child accident prevention in the home. Foreign body in eye. William Phillips Foreskin hygiene.
Ann Salmons Asthma. John Tiller Sleep problems. David Fonda Incontinence of urine. Tim Bajraszewski Osteoporosis. Chris Silagy Smoking—quitting. Grant Connoley Melanoma. Other reference material includes Better Health patient information Victorian Government and patient information conditions from Patient Co.
Hepatitis A. Judith Hammond Premenstrual syndrome. Colleagues who have given considerable advice are Malcolm Fredman. Deirdre Lewis Hirsutism.
Lyndall Whitecross Pill: Jill Rosenblatt Dysmenorrhoea. James Kiepert. Anthony Hall Warts. Diverticular disease. Bruce Barker Angina. Vaginal thrush. Acknowledgments The author would like to thank the Publication Division of the Royal Australian College of General Practitioners for encouraging the concept of patient education and for their permission to reproduce much of the material that has appeared in Australian Family Physician.
Angle Park. Benny Monheit Cannabis. Thanks also to Dr Kerri Parnell and the Editor of Australian Doctor who have agreed to permit publication of selected patient education material that appeared in Australian Doctor in this book. Peter Macisaac Travel: Joan Curtis Autism. Abe Rubinfeld and Lucie Stanford. Talk kindly about your spouse to others—do not put him or her down. Explore the techniques of lovemaking without feeling shy or inhibited.
For most couples this bond will grow. Prepare yourself for parenthood. Learn about family planning methods and avoid the anxieties of an unplanned pregnancy.
Spouses should continue to court and desire each other. The better you know yourself. Seek proper help when necessary. If difficulties arise and are causing problems. Put aside special quiet times each week to share these things.
To split up is a terrible loss in every respect. Making your marriage work When a couple marries. Be proud of each other. The three keys to marital success are caring. Do unto your mate as you would have your mate do unto you. Continue courtship after marriage. This gets back to the unconscious childhood needs. Engage in some high-energy fun activities such as massaging and dancing.
The best environment for a child is a happy marriage. Develop mutual friends. A good sexual relationship can take years to develop. Going out regularly for romantic evenings and giving unexpected gifts such as flowers are ways to help this love relationship.
Any marriage based on this rule has an excellent chance of success. Positive guidelines for success 1. Plan your family wisely and learn about child bearing and rearing. Know yourself. Good grooming and a clean body are important. Cherish your mate. Share interests and goals. Many troubled couples have achieved great happiness by following some basic rules of sharing. Your general practitioner will be able to help. Make love. Learn about sex and reproduction.
Those at high risk include those previously affected and those with a family history. Consider health insurance cover. Getting pregnant Most normal. Genetic or developmental disorders need to be considered if there is a history of a genetic condition in the family. Alcohol and other social drugs. Serious infections Blood group Most conceptions have ideal outcomes but the fetus can be affected by certain infections.
Also carefully wash raw vegetables. Reduce or stop caffeine intake. Avoid high-level exercise and getting overheated. It is a good idea for both partners to know their blood group so they know their Rhesus factor.
Caffeine intake should also be reduced. A negative blood group in the female combined with a positive group in the male partner requires careful attention. A high-fibre. Have a good exercise routine. Commonsense and scientific evidence tell us a healthy body is the best environment to achieve implantation of the fetus and carry it to term.
Eat freshly cooked and prepared food. Iodine intake is important. Women should aim for an ideal weight before conception. Drink lots of water preferably filtered. Immunisation against hepatitis B is advisable. If contracted during pregnancy. These infections. Follow a healthy diet rich in iron and calcium. These infections include rubella.
Eat freshly cooked or freshly prepared food. All other women should have 0. Genetic disorders include thalassaemia. Folic acid before pregnancy Folic acid reduces the risk of having a baby with a neural tube defect such as spina bifida. Get moderate sunlight exposure to boost your vitamin D. Ensure rubella. Stop alcohol and other social drugs.
Pregnancy planning Planning to become pregnant? To prevent listeria infection avoid unprocessed foods such as unpasteurised milk. Nutrition It is important to have a well-balanced and nutritionally sound diet.
Infected cats can transmit toxoplasmosis. Have a breast check and Pap test. Consider genetic and family history. Women over 35 or who smoke can take twice as long to conceive. Most women these days have been vaccinated and are probably immune but this immunity can wear off. Exercise Vaccination Rubella German measles acquired during pregnancy is a big concern.
Avoid exposure to passive smoke and get a smoking partner to cooperate. To avoid toxoplasmosis pregnant women should get another person to clean cat litter boxes daily. Intercourse 3 to 4 times a week at ovulation time maximises the chances of conception. Your doctor will advise about testing for you and your partner.
Genetic counselling Sensible. Most pregnancies invariably go smoothly. Down syndrome and Tay—Sachs disorder. Review current medications. Stop other recreational drugs and discuss over-the-counter drugs with your doctor. The National Health and Medical Research Council advises against drinking alcohol before and during pregnancy.
Take folic acid for 4 weeks before conception. It can take up to 6 months after stopping the contraceptive pill for ovulation to resume. Varicella chickenpox is best avoided and the same rules apply as for rubella. When should you contact your doctor or the hospital? Contact your doctor or seek medical help: Eat most: A special possible problem is pregnancy-induced hypertension. Folic acid is now recommended for 4 weeks and preferably 12 weeks before getting pregnant. It is important to check the many things that can cause problems—these are uncommon.
Eat least: Normal activities You should continue your normal activities. Talk to your doctor about Listeria infection. Areas that need to be checked include: Avoid standing in trains. Your baby is very special and deserves every opportunity to get a flying start in life by growing healthily in your womb. Bran with cereal helps prevent constipation in pregnancy.
Avoid international air travel after 28 weeks. About your pregnancy Congratulations on becoming an expectant parent—this is a very exciting time in your life.
Antenatal classes Trained therapists will advise on antenatal exercises. Breastfeeding and nursing mothers Breastfeeding is highly recommended. Why have regular checks?
Antenatal care is considered to be the best opportunity in life for preventive medicine. Drink ample fluids e. Eat moderately: What common things can cause problems in the baby? An ultrasound is usually performed at about 18 weeks.
Nutrition A healthy diet is very important and should contain at least the following daily allowances: Employment and travel Check with your doctor. When should you be checked? The recommended routine is as early as possible and then every 4 to 6 weeks until 28 weeks of pregnancy. Pregnancy is a very normal event in the life cycle and usually goes very smoothly.
Help is only a telephone call away. Insufficient supply Studies have shown that many women wean because of low milk supply. If there is insufficient supply. How are engorged breasts managed? There is an increased supply of blood and other fluids in the breast as well as milk. An opening is left for the nipple and the leaves are usually changed every 2 hours when appropriate. This is sometimes a problem in mothers who tend to be under a lot of stress and find it hard to relax. As your breasts are used in this way.
Some women prefer to use hot packs. As a rule. Many women use washed. Mothers tend to underestimate their milk supply. Breastfeeding and milk supply Difficulties with breastfeeding are common. Offer the second breast if the baby appears hungry. Engorged breasts What is engorgement? In some women. Remember that there is always some milk present in your breasts. The problem is due mainly to lactation mismanagement such as poorly timed feeds. What should you do? What will you notice?
The breasts and nipples may be so swollen that the baby is unable to latch on and suckle. This is called engorgement. Remember that regular feeding is the best treatment for your engorged breasts. The soreness makes it difficult for you to relax and enjoy your baby. Others notice leaking from the other breast or nothing at all. You are both learning this. When breasts are allowed to remain full. If your supply is low. Once breastfeeding is well established.
Positioning the baby on the breast 2. If you are anxious. Establishing breastfeeding There are three important things that you should know about breastfeeding: This is hard to see yourself. Do not try to bring your breast to the baby. Aim your nipple at the top lip.
If possible. This means that the more the breasts are emptied. Your baby automatically controls his or her food intake by taking as much as needed. When the baby needs to increase your supply. Supply and demand Your breasts produce milk on the principle of supply and demand. The milk higher up in the breast the hindmilk is rich in fat and kilojoules. Usually your breasts will feel fuller after a few days of resting and expressing.
Some women notice a tingling or a pins-and-needles sensation or a fullness when this occurs. Let down When your baby is feeding. You can offer this milk to your baby after the next feed or in the evening.
Supply and demand Occasionally some women experience engorged breasts or insufficient milk supply until breastfeeding is fully established. What are the symptoms? You may feel a lump and then a sore breast at first. What is the treatment? A breast abscess is diagnosed by ultrasound examination. It is quite safe to continue breastfeeding with the affected breast unless your doctor advises otherwise. It is caused by a cracked nipple or blockage of the ducts due to a problem with drainage of the milk.
Apart from the bacterial infection. If you are allergic to penicillin. Faulty drainage can be caused by an oversupply of milk. Keep the breasts draining by expressing or by waking the baby for a feed if he or she sleeps for long periods. For an oversupply. It is safe to do so. It is important to make sure your milk drains well. How can it be prevented? Breast engorgement and cracked nipples must be attended to. Avoiding caffeine and smoking may also help. Golden rule: Candida infection usually causes severe breast pain—a feeling like a hot knife or hot shooting pains.
Doctors regard it as a serious and rather urgent problem. Then follows a red. Mastitis with breastfeeding What is mastitis? Mastitis is an area of inflammation of breast tissue. What are the risks? If treated early and properly. Germs from the outside get into and grow in the stagnant milk. This is usually considered to be up to the 20th week. Miscarriage After a miscarriage you will undoubtedly be confused and wondering why this sad event happened to you.
After a miscarriage. If so. There is no special treatment to prevent any further miscarriages. It is a common cause of miscarriage. At this stage it is called a threatened miscarriage. Other aspects of treatment include: Sometimes it is complete when both fetus and afterbirth are expelled.
Pay attention to any adverse emotional reactions—make sure you talk about any unusual feelings. The odds favour your next pregnancy being successful. What are the surprising facts? The bleeding may then stop in a few days. This abnormality may be caused by a genetic disorder. It is usual for only some parts to be passed to the outside. Will it happen again?
Talk over your feelings with your partner and family. When the solid products are passed. It is best to wait until you have had at least one normal period.
A loss after this time is called a stillbirth. This is referred to as an incomplete miscarriage or abortion. Often the mother is unaware that she has picked up a serious infection such as rubella. Use sanitary towels and not tampons for the next 4 weeks. What is the cause of miscarriage? Most miscarriages occur without an obvious cause. Your next period may be heavy and abnormal. If you get fever. You will need at least a week off work.
In other cases. Make sure that your body is ready before having sex again. It usually takes a while to become interested in sex again. The first symptom is loss of blood from the vagina. How soon should you wait before trying again? You can safely start trying to get pregnant again very soon. The main thing is to remember that it was nothing that you did wrong.
What is a miscarriage? A miscarriage. The mother may also have a clotting disorder of the blood. If it persists. Any pain when the baby latches on indicates incorrect attachment. Candida infection and spasm of the nipple. Feeding is usually very painful. Nipple problems while breastfeeding Sore nipples How are cracked nipples managed? Sore nipples are a common problem and are considered to be caused mainly by the baby not taking the nipple into its mouth properly.
Draw an imaginary cross on the breast with the vertical and horizontal lines crossing at the nipple. At first. Inverted nipples What is an inverted nipple? It is a nipple that inverts or moves into the breast instead of pointing outwards when a baby tries to suck from it. Other causes include a tongue tie in the baby. Your partner can assist with gentle oral and manual stimulation of your breasts and nipples. Do not wear a bra at night.
The nipple will become erect and is then easier to grasp. Cracked nipples nearly always heal when you get the baby to latch onto the breast fully and properly. A sharp pain in your nipple with sucking probably means a crack has developed. Avoid drying agents such as methylated spirits. The key point is to establish correct attachment. Repeat this procedure about 5 times each morning.
A simple treatment. Before breastfeeding. After the baby is born. Not drying the nipples thoroughly after each feed and wearing soggy breast pads are other contributing factors. Place the thumbs or the forefingers opposite each other at the edge of the areola on the imaginary horizontal line. How are sore nipples managed? It is important to be as relaxed and comfortable as possible with your back well supported and for your baby to suck gently.
Check that your baby is correctly positioned on the breast. It usually takes only 1 to 2 days to heal. When the areola is squeezed.
The crack is either on the skin of the nipple or where it joins the flat. Untreated sore nipples may progress to painful cracks. They can observe and teach the correct technique. Cracked nipples Cracked nipples are usually caused by the baby clamping on the end of the nipple rather than applying the jaw behind the whole nipple.
Make sure each position is correct. During pregnancy. In the vertical position. Never pull the baby off the nipple. Press in firmly and then pull the thumbs or fingers back and forth to stretch the areola. If the blues last longer than 4 days. All you really need is encouragement and support from your partner.
It is important to get plenty of help and rest until they go away and you feel normal. Exhaustion from lack of sleep. It is most important to consult your doctor and explain exactly how you feel. Your problem can be treated and cured with appropriate support. You need help. Support groups There are some excellent support groups for women with postnatal depression.
Take your baby to the childhood centre for review. The depression ranges from mild to severe. Some or all of the following may occur: There are two possible separate. Postnatal depression About 1 in 8 mothers develop a very severe depression within the first 6 to 12 months usually in the first 6 months after childbirth.
This is a very serious problem if not treated. It is caused by the marked hormonal changes of pregnancy. Postnatal depression It is quite common for women to feel emotional and flat after childbirth. There may be risks to you. The onset is usually in the first 3 days after childbirth. You must be open and tell everyone how you feel. Both the mould and its cause should be eliminated. Some reactions are caused by food additives such as colourings.
Respiratory system includes nose.
What is the management? Feeding Breastfeeding of allergy-prone babies for the first 6 months might diminish eczema and other allergic disorders during infancy. Get advice from your doctor or infant welfare nurse. If breastfeeding is not possible. Is allergy inherited? Allergy cannot be inherited directly by children from their parents. The correct diagnosis is a matter for your doctor.
Be alert! Vacuuming regularly and keeping pets outside will reduce the problem. The allergic reaction to dairy products. Read labels carefully to check ingredients in products. As a result the body produces naturally occurring inflammatory chemicals called IgE antibodies.
Particular care should be taken when starting foods that most commonly cause allergic reactions dairy products. Symptoms may be any of the following: Allergies are common in babies and children. Other allergies Many babies and children develop allergies to house dust and animal hair. Allergies are not infectious and cannot be transmitted from child to child. The condition is also called atopy.
What are the causes? Common causes of allergic reaction are foods and airborne irritants. How to tell if a baby has an allergy An allergic reaction might take hours or even days to develop and can affect almost any part of the body. They should be avoided during the first 6 to 9 months. Start one food at a time. Allergy in your baby What is allergy? Damp and poorly ventilated homes are subject to mould. What happens when solids are introduced? Unlike most of the common childhood illnesses such as measles and chickenpox.
Air bedding regularly. Digestive system includes stomach and intestines: They usually disappear as the child grows older. New foods should be introduced at least several days apart.
The quantity can be increased the next day if no reaction occurs. In an emergency Call an ambulance if your child is: Asthma in children What is asthma? What is the medicine for asthma?
Asthma is a common chest condition that affects the small air passages bronchi of the lungs. How long does an attack last? It may last from a few hours to a few days.
This can be done using a: About 1 child in 4 or 5 may wheeze and at least half of these have only mild asthma. There are medicines that really help children with asthma. These symptoms should be checked out by your doctor. If your child is having asthma attacks more than once a month. Three types of medications used in children are: They are plastic chambers that make delivery easier to manage and allow the medication to get well into the lungs. Often it is difficult to know what has caused an attack.
It is usual to use spacer devices. The cough is most likely to occur during the night usually in the early hours of the morning. Most children are normal between attacks. The Asthma Action Plan Ask your doctor or asthma nurse educator to provide you with an Asthma Action Plan for an acute attack or for an emergency situation. Remember to keep a smoke-free environment at home and in the car. A persistent cough may be a symptom of asthma. This makes it harder for the air to flow in and out of the lungs.
A guide to what to do is as follows: What causes asthma? Asthma is brought on in different ways for each child. In infants and toddlers a face mask attached to the spacer is used to help deliver the aerosol to the lungs. How do I know if my child has asthma? The main symptoms are a cough. During an asthma attack these breathing tubes become narrow from the spasm of the muscles in the wall and the secreting of mucus.
While waiting for the ambulance. In infants it usually starts on the face and scalp. The child may be very irritable and uncomfortable. It is not contagious. Medical help Your doctor.
Atopic eczema What is atopic eczema? It is not a dangerous condition. The relationship of diet to eczema is controversial and uncertain. Alpha Keri and a bland cleansing agent e. It tends to be coarse. Many children have outgrown it by late childhood. It tends to improve from 1 to 2 years. No particular cause has been found.
Contact with herpes simplex cold sores can produce nasty reactions. Typical sites of infantile eczema What things appear to aggravate eczema?
Eczema or atopic dermatitis refers to a red. Use sorbolene or paraffin creams e. The value of allergy testing is doubtful. Egozite baby cream or others that help. Soaps and detergents Rough and woollen clothes Animal fur Abrasive surfaces e. What ages are affected? What about skin tests and injections?
Eczema usually starts in infants from any age. Atopy refers to an allergic condition that tends to run in families and includes problems such as asthma. Medication The use of medicines for ADHD is controversial but there are effective medications available. It affects about 1 in 20 to 30 children and is far more common in boys. How does the child with ADHD affect the family? ADHD is a developmental disorder of children with the key features of problematic behaviour.
What is the outlook? As a rule children do not grow out of ADHD. It is usually present from early childhood. Not all children with ADHD are overactive and not all children who are inattentive. Having ADHD does not imply that the child has an illness or is not intelligent. There has to be a consistent pattern to the behaviour and not an occasional breakdown in attention span or impulsive acts. It is very important to accurately diagnose ADHD before putting such a label on the child—there are no foolproof diagnostic tests.
The child should be assessed by an expert in the area. If the prescribed drug proves helpful. The patience of all members of the family can be stretched to breaking point. The strategies include positive parenting and teaching behaviour strategies.
There are many things that can be done to help children and their families. What are other features? Day-to-day problems can include some or all of the following: The child needs much understanding and support from the family. Parents usually come in looking exhausted and frustrated with the comment. What is the cause of ADHD? The cause is not clearly known but many experts believe that it has a hereditary basis.
The symptoms must be present in at least two situations. Is a special diet recommended? It is always valuable to encourage a good. Your doctor will be able to advise on the best option.
A special exclusion diet such as avoiding junk foods. Symptoms range from mild to severe. Your doctor can make an assessment of the child and arrange a referral. Although many symptoms can improve with time. The three characteristic features are: Autism, described first by Kanner in , is a developmental disorder commencing in the first 3 years of life. The main features are: There is no medical treatment for autism, although some medications may help for some of the symptoms. Best results are obtained by early diagnosis, followed by a firm and consistent home management and early intervention program.
Later the child will benefit from remedial education, either in a specialised facility or in a regular school with specialist backup.
Speech therapy can help with language development, and nonspeaking children can be taught alternative methods of communication. Most difficult behaviours can be reduced or eliminated by a program of firm and consistent management. Parents and siblings usually need support and regular breaks. What is the cause?