Normative values for the nearpoint of convergence of elementary schoolchildren.

BACKGROUND: Nearpoint of convergence (NPC) values of 8 to 10 cm are widely used to diagnose binocular dysfunctions such as convergence insufficiency. However, there are no published age-related normative values in the literature to substantiate these values. METHODS: Subjects were 297 schoolchildren in kindergarten, third grade, and sixth grade who had passed a school-based Modified Clinical Technique vision screening. Each child had the NPC break and recovery taken three times using a standardized protocol developed by the Convergence Insufficiency and Reading Study group. The examiners used an Astron International (ACR/21) Accommodative Rule with a movable column of 20/30 letters as the target. RESULTS: For each grade, the distribution of NPC break was right skewed, with a concentration of values between 1 and 6 cm. At least 85% of the subjects in each grade had an NPC break < or = 6 cm. NPC break values (mean +/- SD) were 3.3 +/- 2.6 cm for kindergartners, 4.1 +/- 2.4 cm for third graders, and 4.3 +/- 3.4 cm for sixth graders, and the means were found to be statistically different (analysis of variance, p = 0.031). NPC recoveries (mean +/- SD) for the three groups were 7.3 +/- 4.8 cm, 8.7 +/- 4.2 cm, and 7.2 +/- 3.9 cm, respectively, which were also significantly different (analysis of variance, p = 0.027). The recovery distributions were more symmetric and less skewed than those for break. For each grade level, there was a strong positive relationship between NPC recovery and NPC break, but the difference between NPC recovery and break had a low correlation with the NPC break. SUMMARY: Kindergartners had somewhat better NPC breaks than third or sixth graders, whereas no clear age trend was present for NPC recovery. A supporting study using a random sample of clinic patients (aged 10-12 years) suggests that patients with NPC breaks > 6 cm are more than twice as likely to be symptomatic than patients with NPC breaks < or = 6 cm. Based on these results and the NPC break distributions in this study, a clinical cutoff value of 6 cm is suggested for patients of elementary school age. A cutoff value in the 6- to 10-cm range is recommended for children of elementary school age in a screening context. The exact value within this range depends on the level of concern with identifying patients who have visual signs and symptoms associated with a receded NPC.

Moral behavior and the development of verbal regulation.

The present paper examines the relationship between the development of moral behavior and the development of verbal regulatory processes. Relational frame theory and the distinctions among pliance, tracking, and augmenting forms of rule governance are applied to the domain of moral behavior and its development, in order to identify the specific social and verbal contingencies that are responsible for an evolving moral repertoire. It is argued that moral behavior is controlled by relational and rule-following repertoires, and that these can be arranged into a rough progression: pliance, tracking, augmenting, social concern for pliance, social concern for tracking, and social concern for augmenting. Congruence with data derived from other research traditions is examined, and applied implications are explored.

Physicians who have practiced in both the United States and Canada compare the systems.

OBJECTIVES: The aim of this study was to examine the US and Canadian systems from the unique perspective of physicians who have practiced in both Canada and the United States. METHODS: Questionnaires were sent to 355 Canadian physicians who graduated from US medical schools and 347 US physicians who graduated from Canadian medical schools. RESULTS: The overall response rate was 59% (65% of US-graduated Canadian physicians and 54% of Canadian-graduated US physicians). Thirty-six percent of the respondents were "dual experience" physicians; that is, they had practiced medicine in both countries after completing their medical training. Physicians who left Canada were more likely than those who left the United States to indicate dissatisfaction with the health care system as a reason for leaving. Respondents expressed greater professional satisfaction with their current country of practice, but overall, dual-experience physicians in the United States favored that system only slightly more than the Canadian system, whereas those in Canada rated the Canadian system significantly better than the US system. CONCLUSIONS: The comparatively weak rating of the US system by dual-experience physicians underlines the need for health care reform.

The small rural health department: lessons learned.

Small rural health departments of necessity rely on expertise from outside their departments and often from outside their jurisdictions. Such assistance does not negate the need for active involvement on the part of local staff. Creative solutions can almost always be found to confront this need. The experiences of Alpine County, a small rural California county, provide a case in point.