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Relative Risks of and Absolute Event Rates for the Primary End Point at 30 Days in Various Subgroups heart attack or heartburn buy lopressor canada. The overall treatment effect of enoxaparin as compared to hypertension 38 weeks pregnant discount lopressor 25 mg with amex the unfractionated heparin is shown at the bottom of the figure hypertension organization generic lopressor 50 mg without prescription. For each subgroup hypertension in the elderly cheap lopressor on line, the circle is proportional to the number and represents the point estimate of the treatment effect and the horizontal lines represent the 95 percent confidence intervals. Fibrin-specific fibrinolytic agents included alteplase, tenecteplase and reteplase. Time to treatment indicates the time from the onset of symptoms to the administration of study drug (median, 3. Although there was some variation in the estimate of the treatment effect of enoxaparin on the primary endpoint across the subgroups shown, all P values in tests for interaction were non significant. Page 49 of 79 There was a significant treatment benefit of enoxaparin, as compared with unfractionated heparin, in patients who underwent percutaneous coronary intervention within 30 days after randomization (23% relative risk reduction, representing an absolute risk reduction of 3. The main objective of the follow-up period was to assess the subject status at 6-months and 12-months (mortality, myocardial re-infarction, disabling stroke, or re hospitalization). The one-year follow-up period was defined as time of randomization through one-year assessment or last contact (documented by phone contact or patient record). The beneficial effect of enoxaparin on the composite primary end point (death or myocardial re infarction) observed during the first 30 days was maintained over a 12 month follow-up period (see Figure 2). The relative risk reduction in the composite endpoint of death from any cause or myocardial re-infarction observed in the first 30 days after randomization and at 12 months was 17% and 8% respectively. This effect was dose-related and highly specific for factor Xa Page 52 of 79 induced thrombi, even at very low doses. In addition, when enoxaparin was given after the thrombogens, it inhibited further development of an already formed thrombus in rabbits. The potency of the anti-thrombotic effect of enoxaparin was similar to that of heparin in all animal species, although at optimum doses, the effect of enoxaparin was both stronger and more sustained. Both drugs also significantly reduced fibrin deposition following clot induction in an arteriovenous shunt in rabbits. The latter suggests that enoxaparin either acts independently of the platelets or interferes with their binding with factor Xa. Anticoagulant Activity Enoxaparin possesses anticoagulant activity when administered by both the subcutaneous and intravenous routes to the rabbit, dog, monkey and rat. However, doses for anticoagulant activity are much higher than those required for antithrombotic activity. In the monkey, bleeding times were not affected by enoxaparin in doses up to 1000 anti-Xa U/kg s. Repeated subcutaneous and intravenous doses of enoxaparin to monkeys over 4 days still did not alter bleeding times. By contrast, bleeding times increased significantly with heparin and in a dose-related manner. Fibrinolysis Enoxaparin had little or no fibrinolytic activity when given subcutaneously to rabbits, however some fibrinolytic activity was apparent following intravenous injections to rabbits and monkeys. Other Pharmacologic Actions Enoxaparin increased plasma lipase activity in rabbits following relatively high doses (1300 anti Xa U/kg s. Enoxaparin also led to an increase in plasma levels of nonesterified fatty acids, but did not influence plasma cholesterol, triglycerides or phospholipids. Moreover, the drug did not affect water intake, urinalyses or produce occult bleeding in the stools. Page 53 of 79 Drug Interactions There have been no pharmacologic studies on possible interactions between enoxaparin and other drugs. In dogs, signs of toxicity included polypnea, tachycardia, mild agitation, sedation, lateral decubitus, ptyalism, mydriasis and loss of oculopalpebral reflex; all dogs recovered completely. Likewise, single intradermal injections of up to 50% enoxaparin for 1 to 3 weeks, followed by epicutaneous application of the drug, revealed no allergenic potential or local intolerance in 40 male Pirbright white guinea pigs. Long Term Toxicity Subacute and chronic toxicity studies were conducted in rats, dogs and monkeys. There were no species differences in the toxicity of enoxaparin; in all animals there were changes in hematology values and organ weights, reflecting the physiological adaptation of animals to long term anticoagulant treatment and resulting hemorrhage. In 26-week studies, the highest non-toxic dose was 3 mg/kg/day in both rats and monkeys. In the Rat 13-Week, Subcutaneous Administration Wistar rats received enoxaparin in doses of 3, 6. Histopathological examination revealed dose-related hemorrhage and hematomas at the injection site. Mortality rates of about 30% occurred among animals taking the two highest doses (versus 2% of control animals and 3% of animals on the lowest dose). Platelet counts were elevated in all treated animals, but normalized during a post treatment recovery period. These hematology responses were considered normal sequelae of anticoagulant activity, rather than toxic manifestations. Cholesterol levels in all males and in high dose females were elevated above control values in both treatment and recovery phases. Terminal absolute and relative organ weights for the spleen and liver were elevated in dose related manner. Histomorphological examinations revealed bleeding at the injection site, but no toxicopathological effects. In all animals, inflammation, hemorrhage and necrosis were observed at the injection site. Mortality was dose related, death being due to internal hemorrhaging, particularly into the abdominal cavity. With the highest doses, serum urea was elevated, which was likely a result of tubular nephrosis of the kidney and renal capsular hemorrhage seen at autopsy. In addition, organ weights of the spleen, adrenal gland, kidney, heart and liver were increased. In the Dog 13-Week, Subcutaneous Administration Beagle dogs (6 animals per dose) received enoxaparin for 13 weeks in doses of 0, 3, 6. Mild dose-related local hemorrhaging occurred at the injection site, but almost no subcutaneous hemorrhaging. Hematology and biochemistry values remained normal throughout the study and histopathological findings at necropsy revealed only mild parathyroid hyperplasia in dogs given the highest dose. In the Monkey 26-Week, Subcutaneous Administration Cynomolgus monkeys (7 animals/sex/group) were given enoxaparin in doses of 0, 3, 10 and 20 mg/kg/day s. After 6 months, 2 animals/sex/group were selected for 6 weeks of observation of recovery. Dose-related inflammation of the injection site was observed, but symptoms generally disappeared by the end of the recovery period. Organ weights for the kidney, liver and spleen were elevated in the mid and high dose animals and remained elevated in the male animals of the high dose group after the recovery period. One monkey in the high dose group died, although it had had no excessive bleeding or abnormal histopathological signs at autopsy. Other doses produced dose-related inflammation and hemorrhaging at the injection site. Swelling of the arms or legs gradually disappeared by the end of the dosing period. During treatment, hematology, biochemistry and urinalysis values in all treated animals corresponded to those of control animals. Histopathological examination revealed no drug related changes in individual organs. Mutagenicity Enoxaparin exhibited no mutagenic activity when tested in vitro by the Ames test in 5 strains of S. Likewise, no mutagenic activity could be demonstrated in vitro in a mammalian cell system, mouse lymphoma cells, with and without metabolic activation. The clastogenic potential of enoxaparin was tested in vitro in human peripheral lymphocytes and in vivo in the bone marrow cells of rats. Reproduction and Teratology Fertility and Reproduction In the Rat Reproductive performance was evaluated in 26 male and in 26 female sexually mature Sprague Dawley rats (identified as the Fo generation of animals). Starting 15 days before mating, all animals received 0, 3, 10 or 20 mg/kg/day enoxaparin subcutaneously. Treatment continued through mating, gestation and lactation to 4 days post partum.

This may take around 12-16 hours for first children or about 6-9 hours for women who have previously given birth arrhythmia and pregnancy cheap 50mg lopressor. The baby is then rotated so that one shoulder can come through and then the other shoulder blood pressure chart for 60 year old lopressor 50mg on-line. At this stage blood pressure and alcohol cheap lopressor 12.5mg with mastercard, an episiotomy or incision made in the tissue between the vaginal opening and anus blood pressure chart bpm buy lopressor with mastercard, may be performed to avoid tearing the tissue of the back 61 of the vaginal opening (Mayo Clinic, 2016). More than 50% of women giving birth at hospitals use an epidural anesthesia during delivery (American Pregnancy Association, 2015). An epidural block is a regional analgesic that can be used during labor and alleviates most pain in the lower body without slowing labor. The epidural block can be used throughout labor and has little to no effect on the baby. Medication is injected into a small space outside the spinal cord in the lower back. An epidural block with stronger medications, such as anesthetics, can be used shortly before a C-section or if a vaginal birth requires the use of forceps or vacuum extraction. In the United States, about one in three women have their babies delivered this way (Martin et al. These can include: Health problems in the mother Signs of distress in the baby Not enough room for the baby to go through the vagina the position of the baby, such as a breech presentation where the head is not in the downward position C-sections are also more common among women carrying more than one baby. Although the surgery is relatively safe for mother and baby, it is considered major surgery and carries health risks. Additionally, it also takes longer to recover from a C-section than from vaginal birth. However, more than half of women who have a C-section can have a vaginal birth later. Induced birth: Sometimes a babys arrival may need to be induced or delivered before labor begins. Inducing labor may be recommended for a variety of reasons when there is concern for the health of the mother or baby. For example: the mother is approaching two weeks beyond her due date and labor has not started naturally the mothers water has broken, but contractions have not begun There is an infection in the mothers uterus the baby has stopped growing at the expected pace There is not enough amniotic fluid surrounding the baby the placenta peels away, either partially or completely, from the inner wall of the uterus before delivery the mother has a medical condition that might put her or her baby at risk, such as high blood pressure or diabetes (Mayo Clinic, 2014) 62 Assessing the Neonate the Apgar assessment is conducted one minute and five minutes after birth. This tool has been used around the world to further assess the newborn, especially those with low Apgar scores, and to Source: make comparisons of infants in different cultures (Brazelton & Nugent, 1995). Difficulty during delivery may lead to anoxia which can result in brain damage or in severe cases, death. Babies who suffer both low birth weight and anoxia are more likely to suffer learning disabilities later in life as well. Low Birth weight: We have been discussing a number of teratogens associated with low birth weight such as alcohol, tobacco, etc. A child is considered low birth weight if he or she weighs less than 5 pounds 8 ounces (2500 Source grams). A low birth weight baby has difficulty maintaining 63 adequate body temperature because it lacks the fat that would otherwise provide insulation. Such a baby is also at more risk for infection, and 67 percent of these babies are also preterm which can make them more at risk for respiratory infection. Very low birth weight babies (2 pounds or less) have an increased risk of developing cerebral palsy. Additionally, Pettersson, Larsson, DOnofrio, Almqvist, and Lichtenstein (2019) analyzed fetal growth and found that reduced birth weight was correlated with a small, but significant increase in several psychiatric disorders in adulthood. These included: attention-deficit/hyperactivity disorder, autism, depression, and obsessive-compulsive disorder. An insufficient supply of oxygen and nutrients for the developing fetus are proposed as factors that increased the risk for neurodevelopmental disorders. For instance, vaginal infections can lead to premature birth because such infection causes the mother to release anti-inflammatory chemicals which, in turn, can trigger contractions. The earlier a woman quits smoking, the lower the chance that the baby will be born preterm (Someji & Beltran-Sanchez, 2019). A significant consequence of preterm birth includes respiratory distress syndrome, which is characterized by weak and irregular breathing (United States National Library of Medicine, 2015b). After five months in the hospital, Saybie went home in May 2019 weighing 5 pounds. Small-for-Date Infants: Infants that have birth weights that are below expectation based on their Source gestational age are referred to as small-for-date. These infants may be full term or preterm, but still weigh less than 90 % of all babies of the same gestational age. This is a very serious situation for newborns as their growth was adversely affected. Remember that many causes of low birth weight and preterm births are preventable with proper prenatal care. The baby blues are feelings of sadness that occur 3 to 5 days after having a baby, and typically disappear usually within 10 days of the birth. New mothers may have trouble sleeping, be moody, and feel let-down from the birthing experience. Approximately 1 out of 8 women experience postpartum depression and symptoms can include feelings of sadness, sleeplessness, and difficulty bonding with the newborn. Changing hormone levels are thought to be a factor in the occurrence of peripartum depression, however, risk factors include having depression previously, a family history of depression, being younger than 20, experiencing stress, and substance use. Peripartum-onset mood disorders, both depression and mania, can present with or without psychotic features. Hallucinations and delusions are associated with postpartum psychotic episodes and have included command hallucinations to kill the infant or delusions that the infant is possessed. Psychotic features occur in approximately 1 in 500 to 1 in 1,000 deliveries, and the risk is higher for women with prior postpartum mood episodes (American Psychiatric Association, 2013). According to Bregel (2017) because oxytocin, a bonding hormone, rises during preganancy, brain areas related to empathy and anxiety are heightened. Consequently, the new mother is hard-wired to respond to and fend for her baby, which can lead to toxic levels of stress and anxiety. These can manifest as heightened alertness, intrusive and horrifying thoughts of something terrible happening to the infant, and physiological arousal. Just as for peripartum depression and postpartum psychosis, a new mother experiencing postpartum anxiety should seek assistance from a health care provider. Elevated sperm chromosome aneuploidy and apoptosis in patients with unexplained recurrent pregnancy loss. Children of mothers with serious substance abuse problems: An accumulation of risks. Normally occurring environmental and behavioral influences on gene activity: From central dogma to probabilistic epigenesis. The effect of an increase in lead in the water system on fertility and birth outcomes: the case of Flint, Michigan. The early growth and development study: Using the prospective adoption design to examine genotype-interplay. Trends and characteristics of home and other out of hospital births in the United States, 1990-2006 (United States, Center for Disease Control). In Tennessee, giving birth to a drug-dependent baby can be a crime [Audio podcast]. Excess mortality and morbidity among small for-gestational-age premature infants: A population based study. Thirdhand smoke: A new dimension to the effects of cigarette smoke in the developing lung. American Journal of Physiology: Lung Cellular and Molecular Physiology, 301(1), L1-8. Association of maternal cigarette smoking and smoking cessation with preterm birth. Extended maternal age at birth of last child and womens longevity in the Long Life Family Study. Trends in smoking before, during, and after pregnancy Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 20002010. The effect of gestational ethanol exposure on voluntary ethanol intake in early postnatal and adult rats.

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Cautions and things to arteria dorsalis scapulae buy genuine lopressor on-line avoid Y Inconsolable crying should be investigated Y Ensure that dummy-sucking doesnt interfere with feeding by using only when baby isnt hungry arteria testicularis 100 mg lopressor mastercard, such as afer or between feeds arteria renalis order 100 mg lopressor with visa. Parenting tips / Skills to blood pressure medication and zoloft lopressor 50mg sale support infant development Y the newborn baby needs support as he/she is developing greater coordination with their head, body and limb movements. Child and Youth Health Practice Manual 113 Section 2 Birth to fve years [0 to 12 months] 24,41,68,90,120,127,132,134 Emotional wellbeing Infant behaviour Y Infants learn social skills and interaction by observing those around them and by their own experiences of social interaction. A secure attachment develops when consistent and sensitive love and care is ofered to the infant. Parenting tips / Skills to support infant development the child health professional can promote positive parenting behaviours and a parenting style that supports healthy infant-parent relationships. Parents can be encouraged to: Y Have fun interacting with their infant face-to-face en face position is benefcial with newborns. Comfort their infant when they cry and talk about not being able to spoil an infant by responding to them; Y Smile at the infant when they smile at you. Cautions and things to avoid Y Parents can be encouraged to: z Reflect on their parenting style and the factors impacting on it. See appendix 2 114 Child and Youth Health Practice Manual 2014 Section 2 Birth to fve years [0 to 12 months] 24,90,120,127,141 Speech, hearing and vision Infant behaviour Y Babies startle in response to loud noises and turn their head to the direction of their parents voice early on, a reassuring feature for parents that the infant can hear. Infants start putting vowel sounds together and use communications with their body. Reading, talking and singing to infants helps them to develop their language skills. Drooling gradually lessens as the infant develops full control of the musculature of the mouth Y Teething: While teeth erupt at diferent times from one infant to another, teething is a common challenge for parent due to the discomfort it may cause as the crown of the tooth breaks through the periodontal membranes. The frst tooth appears between 6-10 months of age with all 20 baby teeth usually appearing by the time the infant is three years. Parenting tips / Skills to support infant development Y Parents can be encouraged to: z Keep the infants skin clean and dry by the use of bibs when drooling is excessive. Cautions and things to avoid Y Avoid leaving an infant with a bottle when going to bed Y Never use honey on a pacifer Raising Children Network | raisingchildren. The following information provides practice points to guide child health care professionals ofering health promotion advice: Y Encourage families to create an environment whereby mealtime is a pleasurable time spent with other family members 116. Pasteurised milks ofer a rich source of protein and calcium and can be added to the childs diet from one year onwards. Ofering pasteurised cows milk should be limited to around 500mls / day however to avoid the risk of reducing the variety of food intake best for a child 81. Afer two years the child can drink the reduced-fat products with the rest of the family 81. For example factors that may be contributing to the rising rates of obesity include: z regularly consuming large meal sizes z a family culture of admonishing children for leaving food on their plates 24. Child and Youth Health Practice Manual 117 Section 2 Birth to fve years [One to fve years] Y Families should avoid z Foods poor in nutrient value or high in salt, fat or sugar z Hard foods. Breastfeeding Y Breastfeeding is the physiological normal way for a child to feed and is unequalled at providing optimal nutrition and healthy growth for as long as the mother and child desire 41, 94. Child healthcare professionals should encourage the mother to consume a healthy diet while breastfeeding 24. Other population groups may require other supplements when breastfeeding for example: vegan breastfeeding women. These women should consult their health care professionals for individual advice 81. The child health professional should encourage mothers to discuss options with their employer regarding support of breastfeeding. Extended breastfeeding There is no public health recommendation of when a mother and child should cease breastfeeding 135. Mothers who continue to breastfeed past infancy are ofen exposed to society constraints, with some women describing being under surveillance by their community 135. Women who choose to breastfeed children may need additional support from their child health professional with continuing feeding when their societal norm is infant breastfeeding 135. Child health professionals may advocate for breast feeding information to include pictures of children breastfeeding, rather than just babies breastfeeding to assist in addressing cultural barriers 135. Child and Youth Health Practice Manual 119 Section 2 Birth to fve years [One to fve years] Age Average growth 24 4 to 5 years Y Growth on average: z length increase of 7. Cognitive development Child health professionals inform parents about how their childs ongoing development is linked to advances in behaviours in this age group, for example: Y Myelination of the spinal cord becomes complete, resulting in an opportunity for the child to develop bladder and bowel control, with day time toilet training ofen being achieved around the age of 2 years 24. Parent-child interaction Promoting the development of healthy parent-child relationships is seen as one of the best ways to promote child emotional wellbeing and positive mental health. The period of one to fve years encounters incredible advances in child development and a balancing of the need of security toward the parent and the desire to explore their environment and assert themselves116. This can be at times, a threat to the parent-child relationship, but at the same time ofers an opportunity for the child and parent to learn and experiment with conflict and conflict resolution. When this process and experience progresses successfully (most of the time), both the child and parent learn valuable life lessons and relationship skills 116. Refer families to resources to raise their awareness of delays in development such as the: the Red Flag Early Intervention Referral Guide for Children 0 5 years 90. See appendix 1 and 2 Normal behaviour and activities to support development: one to fve years Child health professionals inform parents about the enormous variation of activity and sleep among children depending on their environment and individuality, including: temperament, behavioural characteristics 116, 128. The following tables ofer a guide only, to a childs behaviours patterns and activities and ofers 120 Child and Youth Health Practice Manual 2014 Section 2 Birth to fve years [One to fve years] strategies and tips that may enhance their childs development. When parents raise concerns about their childs behaviour, discuss these concerns with the parents and refer families to resources to raise their awareness of delays in development such as the: the Red Flag Early Intervention Referral Guide for Children 0 5 years. Referral may also be appropriate 24, 58, 115,132 Sleep Child behaviour Y A childs behaviour changes as they become tired Y Children can become overtired quickly Y 1 3 years: z average total sleep/day = 10-16 hrs z One nap a day in most infants 18 months of age, transitioning to no naps. Parenting tips / Skills to support infant development Y Develop a regular bedtime routine. Understanding sleep: 20 frequently asked questions, Tired signs in babies and children, Sleep Issues: Calling out and getting out of bed, Night terrors Child and Youth Health Practice Manual 121 Section 2 Birth to fve years [One to fve years] 24,136,204 Physical activity: exercise and play Child behaviour Y Children should be involved in physical activity every day for at least 3 hours spread across the day. They engage in various types of play, especially enjoying imitative free play without ridged rules where they can act out and make sense of their world. Parenting tips / Skills to support infant development Y Walk to things when you can. Cautions and things to avoid Y Screen time is a major obstacle to physical activity in children [116]. Other milestones are also necessary however to prepare the child to toilet train, including communicating this sensation to the parent and learning the process of holding on and letting go. Girls ofen until four years of age and boys until around fve years Parenting tips / Skills to support infant development Y Encourage a childs recognition of urges, toileting attempts and successes. Cautions and things to avoid Y Avoid punishing a child for not getting to the toilet on time Y Avoid commencing toilet training around stressful family events eg: birth of another baby, moving house. Child and Youth Health Practice Manual 123 Section 2 Birth to fve years [One to fve years] 41,81,120,140,141 Mealtimes Child behaviour Y Generally by 1 year, children can be eating the same foods as the rest of the family. Children experience decreases in appetite as their growth slows and at times may develop periods of fussiness and strong taste preferences. This inconsistency can make it difcult for parents, so developing family principles around mealtimes may be helpful. Parenting tips / Skills to support infant development Y Parents can be encouraged to z Establish family routines around mealtimes. Cautions and things to avoid Y Avoid forcing a child to eat and using punishments specifc to eating. Dental and periodontal disease causes pain and discomfort and can result in personal disfgurement with 25% of all adults over the age of 15 years reporting an experience of discomfort regarding their dental appearance. Parenting tips / Skills to support infant development Y Parents can be encouraged to: z Set up a routine of dental hygiene at least twice a day. Cautions and things to avoid Y Encourage children to let go of their dummies or sucking their thumb or fngers. Health promotion resources Raising Children Network fact sheets and video resources: Raising Children Network | raisingchildren. Teeth development, Cleaning your childs teeth, Visiting the dentist, Caring for your childs teeth. Child and Youth Health Practice Manual 125 Section 2 Birth to fve years [One to fve years] 88,112,120,141 Speech, hearing and vision Child behaviour Y Parents are informed that there is a great variation from one child to another in how much they communication, just are there is with adults. Parenting tips / Skills to support infant development Y Parents can be encouraged to: z Read stories aloud, sing songs, recite rhymes z React, praise their childs eforts to communicate Y If stammering occurs, encourage child to slow and relax, resist completing sentence, take time to listen Y Attend community activities that promote reading and interaction.

For young males arrhythmia treatment order lopressor online now, the rate for fatal crashes was approximately 46 per 100 blood pressure medication cause weight gain order 100 mg lopressor free shipping,000 drivers heart attack 2013 buy lopressor 50mg with amex, compared to blood pressure levels in pregnancy purchase lopressor australia 20 per 100,000 drivers for young females. Crash data shows that almost half of teenage passengers who die in a car crash were not wearing a seat belt (Insurance Institute for Highway Safety, 2017). In 36% of rear-end collisions, teen drivers were following cars too closely to be able to stop in time, and in single-vehicle accidents, driving too fast for weather and road conditions was a factor in 79% of crashes involving teens. Distraction was also a factor in nearly 60% of the accidents involving teen drivers. Fellow passengers, often also teenagers (84% of the time), and cell phones were the top two sources of distraction, respectively. This data suggested that having another teenager in the car increased the risk of an accident by 44% (Carney et al. Distraction coupled with inexperience has been found to greatly increase the risk of an accident (Klauer et al. They attribute this to greater driver training, more social awareness to the challenges of driving for teenagers, and to changes in laws restricting the drinking age. Their ability to think of the possibilities and to reason more abstractly may explain the further differentiation of the self during adolescence. Young teens may see themselves as outgoing but also withdrawn, happy yet often moody, and both smart and completely clueless (Harter, 2012). These contradictions, along with the teens growing recognition that their personality and behavior seem to change depending on who they are with or where they are, can lead the young teen to feel like a fraud. With their parents they may seem angrier and sullen, with their friends they are more outgoing and goofier, and at work they are quiet and cautious. Harter (2012) found that adolescents emphasize traits such as being friendly and considerate more than do children, highlighting their increasing concern about how others may see them. Harter also found that older teens add values and moral standards to their self-descriptions. In addition to the academic, social, appearance, and physical/athletic dimensions of self-esteem in middle and late childhood, teens also add perceptions of their competency in romantic relationships, on the job, and in close friendships (Harter, 2006). Self-esteem often drops when children transition from one school setting to another, such as shifting from elementary to middle school, or junior high to high school (Ryan, Shim, & Makara, 2013). These drops are usually temporary, unless there are additional stressors such as parental conflict, or other family disruptions (De Wit, Karioja, Rye, & Shain, 2011). Self-esteem rises from mid to late adolescence for most teenagers, especially if they feel competent in their peer relationships, their appearance, and athletic abilities (Birkeland, Melkivik, Holsen, & Wold, 2012). Role Confusion Erikson believed that the primary psychosocial task of adolescence was establishing an identity. Erikson saw this as a period of confusion and experimentation regarding identity and ones life path. During adolescence we experience 233 psychological moratorium, where teens put on hold commitment to an identity while exploring the options. Those who are unsuccessful at resolving this stage may either withdraw further into social isolation or become lost in the crowd. However, more recent research, suggests that few leave this age period with identity achievement, and that most identity formation occurs during young adulthood (Cote, 2006). Expanding on Eriksons theory, James Marcia (2010) identified four identity statuses that represent the four possible combinations of the dimension of commitment and exploration (see Table 6. Identity diffusion is a status that characterizes those who have neither explored the options, nor made a commitment to an identity. Those who persist in this identity may drift aimlessly with little connection to those around them or have little sense of purpose in life. Some parents may make these decisions for their children and do not grant the teen the opportunity to make choices. In other instances, teens may strongly identify with parents and others in their life and wish to follow in their footsteps. Identity moratorium is a status that describes those who are activity exploring in an attempt to establish an identity but have yet to have made any commitment. This can be an anxious and emotionally tense time period as the adolescent experiments with different roles and explores various beliefs. Identity achievement refers to those who after exploration have made a commitment. During high school and the college years, teens and young Source adults move from identity diffusion and foreclosure toward moratorium and achievement. The biggest gains in the 234 development of identity are in college, as college students are exposed to a greater variety of career choices, lifestyles, and beliefs. A great deal of the identity work we do in adolescence and young adulthood is about values and goals, as we strive to articulate a personal vision or dream for what we hope to accomplish in the future (McAdams, 2013). Developmental psychologists have researched several different areas of identity development and some of the main areas include: Religious identity: the religious views of teens are often similar to that of their families (Kim Spoon, Longo, & McCullough, 2012). Most teens may question specific customs, practices, or ideas in the faith of their parents, but few completely reject the religion of their families. Political identity: the political ideology of teens is also influenced by their parents political st beliefs. Many adults do not align themselves with either the democratic or republican party but view themselves as more of an independent. Their teenage children are often following suit or become more apolitical (Cote, 2006). Vocational identity: While adolescents in earlier generations envisioned themselves as working in a particular job, and often worked as an apprentice or part-time in such occupations as teenagers, this is rarely the case today. Vocational identity takes longer to develop, as most of todays occupations require specific skills and knowledge that will require additional education or are acquired on the job itself. In addition, many of the jobs held by teens are not in occupations that most teens will seek as adults. Gender identity: Acquiring a gender identity is becoming an increasingly prolonged task as attitudes and norms regarding gender keep changing. The roles appropriate for males and females are evolving, and the lack of a gender binary allow adolescents more freedom to explore various aspects of gender. Some teens may foreclose on a gender identity as a way of dealing with this uncertainty, and they may adopt more stereotypic male or female roles (Sinclair & Carlsson, 2013). Sexual identity: According to Carroll (2016), by age 14 most adolescents become interested in intimate relationships, and they may begin sexual experimentation. Many adolescent feel pressure to express interest in opposite-sex relationships, even if they are not ready to do so. This pressure can be especially stressful for those adolescents who are gay, lesbian, bisexual or questioning their sexual identity. Many non-heterosexual adolescents struggle with negative peer and family reactions during their exploration. A lack of parental acceptance, especially, can adversely affect the gay, lesbian or bisexual adolescents emerging sexual identity and can result in feelings of depression. In contrast, adolescents whose familes support their sexual identity have better health outcomes. Ethnic identity refers to how people come to terms with who they are based on their ethnic or racial ancestry. When groups differ in status in a culture, those from the non-dominant group have to be cognizant of the customs and 235 values of those from the dominant culture. In the United States, those of European ancestry engage in less exploration of ethnic identity, than do those of non-European ancestry (Phinney, 1989). Census (2012) more than 40% of Americans under the age of 18 are from ethnic minorities. For many ethnic minority teens, discovering ones ethnic identity is an important part of identity formation. Source Phinneys model of ethnic identity formation is based on Eriksons and Marcias model of identity formation (Phinney, 1990; Syed & Juang, 2014). Through the process of exploration and commitment, individuals come to understand and create an ethic identity.