
##4119575 News Focus </p> Writer David C. Holzman first heard about ecosystem services in current presidential science advisor John P. Holdren 's class " Quantitative Aspects of Global Environmental Problems " at the University of California , Berkeley , in winter quarter , 1975 . The late Lee Schipper , Holzman 's original mentor on energy issues , had recommended the class </p> Healthy ecosystems provide us with fertile soil , clean water , timber , and food . They reduce the spread of diseases . They protect against flooding . Worldwide , they regulate atmospheric concentrations of oxygen and carbon dioxide . They moderate climate . Without these and other " ecosystem services , " we 'd all perish. 1 </p> One hallmark of the history of civilization is an ever-increasing exploitation of ecosystem services coupled with substitution of technology for these services , particularly where ecosystems have been exploited beyond their ability to provide. 2 Agriculture is a hybrid of exploitation and substitution that enabled people to live in greater , denser populations that drove further exploitation and substitution . Modern plumbing made close quarters far less @ @ @ @ @ @ @ @ @ @ break down sewage , and to substitution with expensive sewage treatment technologies . Exploitation of fossil fuels led to a slew of modern conveniences , including fishing fleets that are so effective at catching their prey that they threaten fisheries globally 3 , 4 All this exploitation strained ecosystems , but in the past , when the population was a fraction of what it is now , these strains were local rather than global phenomena . </p> In 2005 the Millennium Ecosystem Assessment ( MA ) , 5 a sweeping survey conducted under the auspices of the United Nations , found that approximately 60% of 24 ecosystem services examined were being degraded or used unsustainably. 6 " Every year we lose three to five trillion dollars ' worth of natural capital , roughly equivalent to the amount of money we lost in the financial crisis of 2008-2009 , " says Dolf de Groot , leader of the Research Program on Integrated Ecosystem Assessment and Management at Wageningen University , the Netherlands . </p> The value of ecosystem services typically goes unaccounted for in business and policy decisions and in market prices @ @ @ @ @ @ @ @ @ @ at all , they are perceived as free goods , like clean air and water . So it 's not surprising that much of the degradation of ecosystems is rooted in what the President 's Council of Advisors on Science and Technology ( PCAST ) , an independent group of U.S. scientists and engineers , describes as " widespread underappreciation of the importance of environmental capital for human wellbeing and the absence of the value of its services from the economic balance sheets of producers and consumers . " 7 PCAST and other groups are working to build recognition of ecosystem services and , importantly , to valuate them -- that is , calculate values for these services to help policy makers and resource managers make rational decisions that factor important environmental and human health outcomes into the bottom line . </p> An Idea Whose Time Has Come ? In July 2011 PCAST called upon the federal government to assess quadrennially the condition of the nation 's ecosystems and the social and economic value of services they provide . The goal was to improve methods for evaluating those services and to @ @ @ @ @ @ @ @ @ @ gather new information in a format that interested parties can easily use. 7 </p> But the concept of valuating ecosystem services is not new . John P. Holdren , now science advisor to President Barack Obama , introduced it to students in his class " Quantitative Aspects of Global Environmental Problems " at the University of California , Berkeley , in the 1970s . He emphasized that technological substitutions for ecosystem services are often costly , sometimes to the point of impracticality , and that sometimes an incomeplete understanding of how they function makes such substitutions impossible . Geoengineering to mitigate global climate disruption in the face of increasing emissions , for example , is widely viewed as extremely risky , because the climate is so complex . </p> In 1997 Robert Costanza , Distinguished University Professor of sustainability at Portland State University , Oregon , and colleagues first estimated that ecosystem services worldwide are worth an average $33 trillion annually ( $44 trillion in today 's dollars ) , nearly twice the global GNP of around $18 trillion ( $24 trillion in today 's dollars ) . 8 Although the @ @ @ @ @ @ @ @ @ @ was widely praised for drawing attention to the value of ecosystem services , says Rick Linthurst , national program director of the Ecosystem Services Research Program at the U.S. Environmental Protection Agency ( EPA ) . </p> Payments to preserve ecosystem services date to at least the early 1980s , when the United States implemented wetland and stream credit banking , 9 but the idea really took off in the mid 1990s . For instance , in 1996 Costa Rica began paying landowners $42 per hectare per year to preserve forest. 10 At the time , that country had the highest deforestation rate in the world ; now it has among the lowest , says Gretchen C. Daily , Bing Professor of Environmental Science at Stanford University . </p> China responded to a devastating drought in 1997 , followed by massive floods in 1998 , by inaugurating various payments for ecosystem services and a policy for conserving areas that are important sources of ecosystem services . These are known as Ecosystem Function Conservation Areas . Among the benefits : soil erosion fell sufficiently to cut sediment in the Yellow River by @ @ @ @ @ @ @ @ @ @ sequestration rose by an estimated 1.3 billion tons between 1998 and 2010 , says Jianguo Liu , the Rachel Carson Chair in Sustainability and University Distinguished Professor of fisheries and wildlife at Michigan State University . But he adds that some benefits probably came at the expense of natural capital elsewhere in the world , as declines in forest cutting coincided with a rise in imported timber . </p> In 2010 the World Bank launched a program to help countries incorporate the value of ecosystem services into their accounting systems with an eye toward managing ecosystems to maximize economic benefit. 11 Colombia , beset for several years by unusually persistent and damaging rains , is one of five pilot countries working with the bank . </p> Elsewhere , Norway is paying Indonesia $1 billion to preserve rainforest for carbon storage and sequestration to limit the impacts of climate change. 12 And in Vietnam , an investment of $1.1 million in mangroves , which protect coastal regions from flooding , saved $7.3 million annually that would have gone to maintaining dikes. 1 </p> A number of agencies of the U.S. federal government @ @ @ @ @ @ @ @ @ @ assembling a national atlas that can overlay visual information , like that used in Google Earth , with ecological and economic analyses to reveal variability in ecosystem service provision . The agency also has pilot programs in four regions of the United States enabling interested parties to project different resource-use scenarios into the future to help guide decision making now. 13 </p> And in 2007 environment ministers from the G8+5 countries 14 agreed to begin analyzing the global economic benefits that derive from ecosystems and biodiversity , and to compare the costs of failure to protect these resources with the costs of conserving them . In the ensuing years , the resulting initiative , The Economics of Ecosystems and Biodiversity ( TEEB ) , 15 has produced a series of reports for decision makers at the international , national and local levels aimed at enabling practical responses . </p> Another leader in guiding decision makers on payments for ecosystem services is the Natural Capital ( NatCap ) Project , cofounded by Stanford 's Daily in 2006. 16 NatCap has created software called InVEST ( Integrated Valuation of Environmental Services and Tradeoffs @ @ @ @ @ @ @ @ @ @ social benefits , so that decision makers can explore the implications of alternative land-use scenarios . For any given piece of real estate , InVEST can take existing data on various ecosystem services -- each of which may fall under a different field of study -- and provide one consistent platform for assessing all of them together , to determine the optimal use(s) of that land , says Heather Tallis , lead scientist of NatCap . For example , " trade-off curves " can reveal how much timber can be harvested before causing major profit loss to hydropower , flood damage , or loss of biodiversity . The tools are available free through NatCap. 17 </p> NatCap 's consulting group is currently working on numerous projects within the United States and with 15 other countries in Africa , Latin America , the Pacific , North America , and Asia . Foremost among those countries is China , which is spending a total of around $100 billion -- more than any other country -- to preserve forestlands through logging bans , to buy farms that are perched unsustainably on steep slopes for @ @ @ @ @ @ @ @ @ @ Chinese government will shift farmers either to more sustainable locations or to other occupations , says Daily . NatCap is using InVEST to assess how many resource-intensive livelihoods -- in farming , forestry , herding , and other fields -- could be supported sustainably in a certain area under given practices , and to evaluate how shifting inhabitants to an alternative mix of livelihoods would impact natural capital and ecosystem services . This helps inform the investments needed to enable desired shifts , as well as to ascertain who will benefit and who will be hurt by the shifts , and to determine appropriate compensation , says Daily . </p> Assigning a Dollar Value Ecosystem services are valued , ideally , by how much human welfare they can provide . The most convenient measure of welfare is dollars , although at this early stage of development of the science , that is not always a practical measure . </p> Values for provisioning services see sidebar , " What Are Ecosystem Services ? " are relatively easy to determine . The simplest and least controversial methods to assess value draw on existing @ @ @ @ @ @ @ @ @ @ of the NatCap Project at the World Wildlife Fund U.S. office . For example , coastal and marine ecosystems support the production of fish . The value of this service can be assessed based on revenues , a function of the price and quantity of harvested fish . </p> Thus , the value of the provisioning service is equal to how much all of its current and future production is worth today -- what economists call its " present value . " The further into the future the production lies , the lower the present value of the service . That 's because money invested today in a safe investment , such as a Treasury bill , almost certainly will grow . If Treasury bills are earning 3% , $100 invested today will become $103 a year from now , $106.09 two years from now , and so on . That means that $106.09 two years from now is no more valuable than $100 today . </p> Many ecosystem services , such as scenery , recreational value , and most regulatory services , including those moderating infectious disease , lack a @ @ @ @ @ @ @ @ @ @ asking people what they would pay for a particular service , says Stephen Polasky Fesler-Lampert Professor of ecological/environmental economics at the University of Minnesota ; this is called " stated preference . " Another method , " revealed preference , " involves determining values from related actual purchases , such as the money people spend to travel to bucolic tourist destinations , or the extra cost of a house with a water view over a similar nearby house without the view . </p> Another valuation technique is estimating " replacement cost . " This is the cost of the least expensive technical fix as a replacement for an ecosystem service . For example , New York City recently paid landowners in its watershed more than $1 billion to change their farm management practices to prevent animal waste and fertilizer from washing into the waterways . In doing so , the city avoided spending $6-8 billion on a new water filtration plant and $300-500 million annually to run it -- the replacement cost of the natural filtration provided by waterways. 1 " Protecting the watershed along with the ecosystem service it provides @ @ @ @ @ @ @ @ @ @ eight billion dollars because that is the cost of replacing the service , " says Polasky who notes that the value of clean water is far higher still . </p> The value of an ecosystem service depends on local and/or regional socioeconomic conditions as well as supply and demand . Thus , the value of clean water is much higher in New York City 's watershed , where it serves 19 million people7 than it would be in , say , Alaska , says Polasky . </p> When it comes to valuating ecosystem services , the economics is the easy part -- easy being a relative term . The major difficulties have more to do with the fact that ecology is a relatively young science , and there is much that we do n't yet understand about it , says Polasky , echoing colleagues . " Nature is probably the most complex system we know of , " Daily explains . </p> Huge Error Bars and Heroic Assumptions Part of the problem , generally speaking , is that the multiple uncertainties about how ecosystems do what they do add up to @ @ @ @ @ @ @ @ @ @ are often based on " heroic assumptions " that do n't stand on much data , says Lisa Wainger , a research associate professor at the University of Maryland Center for Environmental Science . </p> For instance , scientific understanding of feedback among the many ecosystem services remains wanting -- " If you have more carbon in soil , are plants better able to take up nitrogen ? " asks Polasky , as one example . A good deal of ecological uncertainty stems from a lack of information about basic natural history . The PCAST report notes that " groups of organisms likely to be most important in ecological terms , such as species that determine soil fertility , promote nutrient cycling , or consume wastes are among the least familiar and least visible -- e.g. , fungi , nematodes , mites , insects , and bacteria . Populations of ecologically dominant marine organisms , most of which are either invertebrates or microbes , are just as poorly understood . " 7 </p> Climate change magnifies all these ecological uncertainties . It 's " the mother of all externalities , " @ @ @ @ @ @ @ @ @ @ the University of Sussex , " larger , more complex , and more uncertain than any other environmental problem . " 19 Over the rest of the century , global climate shifts are likely to be the biggest driver of ecosystem change and may greatly reduce Earth 's carrying capacity , according to PCAST. 7 </p> It also remains difficult to link changes in the delivery of ecosystem services to changes in human welfare . " There are many mysteries about which species confer what dynamics to ecosystems or what benefits to people , " says Daily . " We really do n't know how much biodiversity is needed to sustain and fulfill human life . " </p> But more precise knowledge of the economic value of those ecosystem services that can easily be valuated " would not , in itself provide insight into what fraction of the benefit would be lost in consequence of a given type or degree of ecosystem disruption , " according to the PCAST report. 7 There are thresholds in ecosystem function beyond which carrying capacity plummets . History and prehistory are littered with thresholds breached @ @ @ @ @ @ @ @ @ @ 's desertified Middle East ( probably due to mismanagement of irrigation , says Daily ) to the deforestation , extinction of all wild land birds , and human population collapse on Easter Island. 2 One of the biggest fears about the impact of climate change is that global thresholds will be breached , but the ability to predict such with anything approaching precision is currently beyond ecological science . </p> Progress Despite the challenges , considerable progress has been made over the last decade toward improved techniques for linking changes in ecosystem services to changes in human welfare . Part of that improvement is due to modeling methods , including InVEST , as well as to greater numbers of ecological studies , and part is due to improvements in the data , says Polasky . The field has been boosted by the revolution in GIS ( geographic information system ) technology and so-called spatially explicit data : " We now have very good images that enable us to know the heights of plants and elevations of terrain , and really good sensors that show us what 's on the ground , @ @ @ @ @ @ @ @ @ @ monitoring . If we increase the deforestation upriver , we can monitor the sediment downriver . That 's been a huge help . " </p> Health &; Ecosystems : Analysis of Linkages ( HEAL ) , 20 a consortium of more than 25 conservation and public health institutions , has embarked on the first rigorous , systematic attempt to measure the human health impacts of changes in a variety of natural systems . HEAL 's projects are designed to evaluate what are thought to be key connections between the environment and health . Examples include the relationships between subsistence hunters ' sustainable access to wildlife and their children 's nutritional needs ( particularly as related to iron and key micronutrient deficiencies ) ; between upland deforestation on islands such as Fiji , erosion and waterborne diarrheal diseases in children , and downstream coral reef health and productivity ; between deforestation patterns and malaria in the Amazon and other major forest systems ; between landscape fires in Sumatra and smoke-related cardiopulmonary illness in the broader region downwind ; and between fishers ' access to Marine Protected Areas , food security , income @ @ @ @ @ @ @ @ @ @ having a " sense of place " related to coastal resource security . </p> Perhaps most importantly , says Steve Osofsky , HEAL coordinator and director of health policy at the Wildlife Conservation Society , the project seeks to quantify all these types of relationships related to communicable diseases , noncommunicable diseases , nutrition , and the social and psychological dimensions of health . In Osofsky 's words , " If it can not be measured , it can not be managed . " </p> The ultimate goal of valuating ecosystem services " is to improve human well-being overall , " says Daily . She cautions that there will always be people who lose out in any policy decision . However , she says , " The aim is to design these investments in natural capital so as to advance human development and alleviate poverty at the same time . This is the Holy Grail . " </p> REFERENCES AND NOTES 1 . TEEB.The Economics of Ecosystems and Biodiversity for Local and Regional Policy Makers . Geneva , Switzerland:The Economics of Ecosystems and Biodiversity Study , United Nations Environment Programme ( @ @ @ @ @ @ @ @ @ @ 2012 . </p> 2 . Diamond J. Collapse : How Societies Choose to Fail or Succeed . New York , NY:Viking Adult ( 2005 ) . </p> 3 . Tibbetts J. The state of the oceans , part 1 : eating away at a global food source . Environ Health Perspect 112(5):A282-A291 ( 2004 ) ; http : **33;73399;TOOLONG . </p> 4 . Tibbetts J. The state of the oceans , part 2 : delving deeper into the sea 's bounty . Environ Health Perspect 112(8):A472-A481 ( 2004 ) ; http : **33;73434;TOOLONG </p> 5 . The MA represents the work of 1,360 experts from 95 countries . The reports focus on the connections between how changes in ecosystem services -- usually involving deterioration -- affect human well-being , and , based on these findings , call into question the ability of ecosystems to sustain future generations . </p> 6 . Millennium Ecosystem Assessment Board . Statement of the MA Board . Living Beyond Our Means : Natural Assets and Human Well-being . Washington , DC and Nairobi , Kenya:World Resources Institute and United Nations Environment Programme ( 2005 ) . @ @ @ @ @ @ @ @ @ @ </p> 7 . The President 's Council of Advisors on Scence and Technology ( PCAST ) . Report to the President . Sustaining Environmental Capital Protecting Society and the Economy . Washington , DC:White House Office of Science and Technology Policy , Executive Office of the President ( Jul 2011 ) . Available : http : **114;73509;TOOLONG accessed 6 Mar 2012 </p> 8 . Costanza R , et al . The value of the world 's ecosystem services and natural capital . Nature 387(6630)253-260 ( 1997 ) ; http : **29;73625;TOOLONG . </p> 9 . EPA . Wetlands Fact Sheet : Mitigation Banking Factsheet website Washington , DC:U.S . Environmental Protection Agency ( updated 12 Jan 2009 ) . Available : http : **44;73656;TOOLONG accessed 6 Mar 2012 </p> 10 . Snchez-Azofeifa GA , et al . Costa Rica 's Payment for Environmental Services Program : intention , implementation , and impact . Conserv Biol 21 ( 5 ) : 1165-1173 ( 2007 ) ; http : **45;73702;TOOLONG . </p> 11 . The World Bank . Wealth Accounting and the Valuation of Ecosystem Services ( WAVES ) : A Global Partnership @ @ @ @ @ @ @ @ @ @ Nov 2011 ) . Available : http : **29;73749;TOOLONG accessed 6 Mar 2012 . </p> 12 . Norad . Real-Time Evaluation of Norway 's International Climate and Forest Initiative . Contributions to National REDD+ Processes 2007-2010 . Country Report Indonesia . Oslo , Norway : Norwegian Agency for Development Cooperation ( 2010 ) . Available : http : **135;73780;TOOLONG accessed 6 Mar 2012 </p> 13 . EPA . Ecosystem Services Research : National Atlas website , Washington , DCU.S . Environmental Protection Agency ( updated 1 Mar 2012 ) . Available : http **35;73917;TOOLONG nattional-atlas.htm. accessed 6 Mar 2012 </p> 14 . The G8+5 includes the heads of government from the G8 nations ( Canada , France , Germany , Italy , Japan , Russia , the United Kingdom , and the United States ) , plus the heads of government of five emerging economies ( Brazil , China , India , Mexico , and South Africa ) </p> 15 . TEEB website , Geneva , SwitzerlandThe Economics of Ecosystems and Biodiversity Study ( TEEB ) , United Nations Environment Programme ( 2012 ) . Available : http : //www.teebweb.org/ accessed @ @ @ @ @ @ @ @ @ @ ( NatCap ) Project is a partnership among Stanford University , the University of Minnesota , the Nature Conservancy , and the World Wildlife Fund . </p> 17 . Natural Capital Project website , Stanford , CA:The Natural Capital Project ( 2012 ) , Available : http : **42;73954;TOOLONG accessed 6 Mar 2012 . </p> 18 . Liu J , et al . Ecobgical and sotioeconomic effects of China 's policies for ecosystem services , proc Natl Acao Sci USA 105(28):9477-9482 ( 2008 ) ; http : **36;73998;TOOLONG . </p> 19 . Tol RSJ . The economic effects of climate change . J Econ Perspect 23(2):29-51 ( 2009 ) ; http : **32;74036;TOOLONG . </p> 20 . One Health Commission . Health &; Ecosystems : Analysis of Linkages http : **108;74070;TOOLONG 6 Mar 2012 . </p> 21 . Daily GC , et al Ecosystem services : benefits supplied to human societies by natural ecosystems . Issues Ecol 2:1-16(1997) ; http : **64;74180;TOOLONG . </p> 22 . Chivian E , Bernstein AS . Embedded in nature : human health and biodiversity . Environ Health Perspect 112(1)A12-A13 ( 2004 ) ; http : @ @ @ @ @ @ @ @ @ @ and communities : evidenced-based nature contact recommendations . Int J Environ Health Res 21(1):41-61 ( 2011 ) ; http : **41;74280;TOOLONG </p> 24 . Keesing F , et al . Impacts of biodiversity on the emergence and transmission of Infectiousdiseases . Nature 468 ( 73241:647-652 ( 2010 ) ; http : **32;74323;TOOLONG . </p> 25 . Myers SS , Patz JA . Emerging threats to human health from global environmental change . Ann Rev Environ Res 34 223-252 ( 2009 ) ; http : **50;74357;TOOLONG . </p> 26 . Riotetts TH , et al . Economic value of tropical forest to coffee production . Proc Natl Acad Sci USA 101(34)12579-12582 ( 2004 ) ; http : **36;74409;TOOLONG </p> By David C. Holzman </p> David C. Holzman writes on science , medicine , energy , economics , and cars from Lexington and Wellfleet , MA . His work has appeared in Smithsonian , The Atlantic Monthly , and the Journal of the National Cancer Institute . </p> </p> 
##4119576 News Innovations </p> Exposures that cause chronic diseases usually take place years , perhaps decades , before disease is diagnosed . Biomarkers collected at single points of time therefore can not tell the whole story of how disease occurs in an individual . For that , one must look to the " exposome , " or the compilation of exposures experienced over an individual 's lifetime . But efforts to link environmental exposures to disease have been stymied by the difficulty of accurately measuring those day-to-day exposures and the substances that are present in people 's bodies . </p> The term " exposome " was initially coined in 2005 by Christopher Wild , 1 who now directs the International Agency for Research on Cancer , in recognition of the failure of genetic factors to explain most variability in human diseases . The exposome concept reflects the reality that people are exposed to potentially health-impairing agents from both pollution and nonpollution sources , including industrial chemicals , combustion emissions , radiation , heat/cold , noise , and food . The exposome also includes behavioral factors , such as activity @ @ @ @ @ @ @ @ @ @ 's expo-some includes his or her microbiome , 2 or vast personalized assembly of commensal microbes . All these exposures and factors can vary over the course of a day , not to mention over the weeks , months , and years that make up a lifetime . </p> In the last few years , tools and methodologies have begun to emerge that hold promise for more easily capturing information about at least some of the environmental exposures that an individual may come into contact with over the course of his or her lifetime . The new tools come from a wide range of disciplines -- some of which fall outside the usual domain of environmental health -- and they are already helping researchers amass data on real-world exposures . These tools also hold promise for conducting studies that uncover unexpected links between environmental exposures and disease . </p> Several of the most promising tools and approaches were discussed at a workshop of the National Academies ' Emerging Science for Environmental Health Decisions committee in December 20ll. 3 Some of these tools are already helping researchers get a handle on how @ @ @ @ @ @ @ @ @ @ disease and cancer , says Steve Rappaport , director of the Center for Exposure Biology at the University of California ( UC ) , Berkeley , who organized the workshop . </p> Measuring External Exposures Tools for measuring the exposome are aimed at assessing exposures that take place both outside the body ( the " exposure dose " ) and inside ( the " absorbed dose " ) ; both are important for determining whether an environmental agent causes actual harm , says Linda Birnbaum , director of the National Institute of Environmental Health Sciences ( NIEHS ) . For example , as some studies have shown , such as research involving measurements of arsenic in soil , house dust , and urine , " a big increase in external exposure may not necessarily result in a major increase in internal exposure . At the same time , if you ca n't tell where an internally measured chemical came from , it 's impossible to prevent the exposure . </p> Some of the new tools for measuring external exposures capitalize on the fact that the majority of the world 's citizenry @ @ @ @ @ @ @ @ @ @ 5 Cell phones already contain components that make them suitable for collecting key information associated with environmental exposures , points out Michael Jerrett , an associate professor in the Environmental Health Sciences program at the UC Berkeley School of Public Health . These instruments include ambient light meters , Global Positioning System sensors , and accelerometers , which measure movement . The latter two instruments can indicate when people travel by motor vehicle , which can be a major source of exposure to air pollutants , he says . </p> In an unpublished pilot study in Barcelona , Jerrett has been testing cell phones ' suitability for tracking environmental exposures . Students ' movements , as tracked by cell phones and other wearable devices , are overlaid on models developed by the city 's Energy Agency and others to predict air pollution levels . Jerrett says measurements collected via cell phones compare quite favorably with those taken by equipment that has traditionally been used to measure personal exposures , which was often the size of a backpack . </p> Another way that cell phones can help researchers is by interfacing with @ @ @ @ @ @ @ @ @ @ is the Bluetooth-enabled SensPod monitor , which collects data on ozone , carbon monoxide , carbon dioxide , nitrogen oxides , noise , and ultraviolet radiation . In Copenhagen , Jerrett says , a network of individual cyclists travel through the city with SensPods mounted on their bikes . The monitors inform the cyclists about their personal exposures as they move through the city , and the data can be uploaded to an application that compiles them into a pollution map . Users can pair their SensPods with an Android smart-phone via a mobile application that lets the two devices communicate and share data with the larger network of SensPod users . People in more than 20 countries in Europe , Asia , and North America are using the mobile sensors , according to Sensaris , the company that makes the devices. 6 It 's no stretch to imagine investigators using these devices for research purposes . </p> Among the investigators working to expand the array of chemicals that can be detected by handheld sensors is Non-gjian ( NJ ) Tao , director of the Center for Biosensor and Bioelectronics at @ @ @ @ @ @ @ @ @ @ a wireless , wearable device the size of a cell phone that is capable of sensing petroleum-derived hydrocarbons , such as benzene , toluene , ethylene , and xylene ( all of which are known or suspected human carcinogens 7 ) . Field-testing at an Arizona State waste management facility showed that the sensor could detect acid vapors associated with waste management , including phosphoric acid and hydrochloric acid . Tao says his devices have proven sufficiently sensitive to detect benzene , toluene , ethylene , and xylene at concentrations of 1 ppb , comparable to commercially available detectors . </p> The tests Tao has conducted to date may be useful for evaluating personal exposures because they can generate results similar to those shown by U.S. Environmental Protection Agency monitoring systems . At the same time , the handheld devices can identify peaks the stationary monitors might miss . Tao is gearing up to begin pilot-testing the monitors in epidemiologic studies . </p> Another important aspect of personal exposure revolves around individuals ' levels of exertion . Stephen Intille , an associate professor in the College of Computer and Information Science @ @ @ @ @ @ @ @ @ @ , led the development of the Wockets system , a wearable device capable of recording people 's physical activity . Such data are important to exposure assessment because physical exertion can change the dose of pollution a person receives . In one study , people driving a car or riding in a bus inhaled about 4.5 L air per minute , whereas subway riders inhaled 10 L/min , people walking inhaled 23 L/min , and cyclists inhaled 37 L/min. 8 </p> Intille 's Wockets are different from consumer-targeted wearable activity monitors , such as heart-rate monitors and pedometers , in that they provide continual data on the type , intensity , duration , and location of the wearer 's upper- and lower-body physical activity for months at a time . They also collect data on compliance so that researchers know whether the monitors are being used . The Wockets were initially designed with input from a group of self-described " non-technophile " volunteers aged 22 to 82 to ensure they are easy enough for even the least tech-savvy study participant to use . Intille 's team has also created " reminder @ @ @ @ @ @ @ @ @ @ prompt participants to comply with research protocols . He hopes to have collected enough data to verify that the Wockets work as promised by the end of 2012 . </p> Because the data from personal sensors such as the ones Sensaris produces can be posted online in near real time , it sets the stage for what Jerrett calls " participatory sensing networks " fed by inputs from wired citizens . ( Although the Wockets data also are available very quickly , access to these data will be strictly controlled by the researchers , Intille stresses . ) Whether the data come from individuals or centralized monitoring stations , they have great educational potential , Intille says -- people participating in the network could learn about potential exposures associated with any given point in space and time , and having detailed data on exposures may also enable researchers to design interventions to reduce exposures , which could be programmed into smart devices . </p> " It 's one thing to know where people are exposed or how much people are exposed to , but once you know that as well as @ @ @ @ @ @ @ @ @ @ help them change their exposure levels , " Intille says . For example , smart technology might reveal when small changes in behavior ( such as staying farther away from the cars ahead of you in traffic or walking a slightly different route ) could effect significant changes in exposure to pollutants that exacerbate asthma , he points out . However , Intille and Jerrett agree that important privacy issues need to be worked out before these concepts can be fully realized . </p> Internal Exposure Data A major advantage of focusing on the internal exposome is that you do n't necessarily need to know exactly what you 're looking for in order to find something important to human health , Rappaport says . " By comparing complex patterns of chemical signals detected in the blood of healthy and diseased persons , it is possible to pinpoint particular chemicals whose levels are higher or lower in the people with disease , " he explains . This , he says , holds promise for helping scientists ferret out and characterize the heretofore unknown risk factors that underlie a large portion of the @ @ @ @ @ @ @ @ @ @ expo-some data include efforts using blood plasma , urine , feces , and cells from inside one 's cheek or nostril . Some of these technologies already exist for other purposes . For example , Rajeshwari Sundaram , an investigator at the Eunice Kennedy Shriver National Institute of Child Health and Human Development , points out that over-the-counter fertility monitors used by couples seeking to become pregnant can be useful for collecting hormonal data from women of child-bearing age . Sundaram is involved in the National Institutes of Health 's Longitudinal Investigation of Fertility and the Environment ( LIFE ) study , which is using the monitors to capture daily changes in levels of reproductive hormones in a group of women who are trying to become pregnant . The LIFE study , which also involves men , is investigating how exposure to a variety of endocrine-disrupting compounds affects hormonally driven issues such as semen quality , time to pregnancy , infertility , pregnancy loss , gestation duration , and birth size. 9 </p> Another project under way to collect internal exposome data is headed up by Avrum Spira , a pulmonologist @ @ @ @ @ @ @ @ @ @ in the human airway as signatures of internal exposure to smoke from tobacco and cooking fires . The group is currently focused on studying airway expression of the small noncoding RNA sequences known as microRNAs , or miRNAs , which regulate the genetic response to smoking. 10 Spira 's group 's work is based on the hypothesis that cigarette smoke and other inhaled exposures alter epithelial cell gene expression throughout the respiratory tract11 and that variability in this gene-expression response is associated with risk for developing lung disease. 12 One of the group 's ongoing projects is to identify novel miRNAs in the airway that may ultimately serve as biomarkers for detecting lung cancer based on a sample that can be easily captured through the nose or mouth . The team is also investigating whether exposure to burning biomass , such as through cooking fires , alters gene expression in these cells . </p> One of the most unexpected findings to result from an internal exposome investigation was published last year , when a group led by Stanley Hazen , head of the Cleveland Clinic 's Preventive Cardiology and Rehabilitation section @ @ @ @ @ @ @ @ @ @ disease risk played by consumption of choline and other nutrients in concert with the micro-biome. 13 According to Hazen , the microbiome is particularly important because it is a filter of what he calls our largest environmental exposure -- what we eat -- and is a major contributor to our internal exposure . </p> Hazen is the principal investigator in a clinical study that is following more than 10,000 patients in a bid to identify small molecules in blood plasma and related pathways that predict an increased risk for major cardiovascular events such as heart attacks . By studying samples from 150 randomly selected people who experienced a heart attack or stroke in the three years following enrollment , together with age- and sex-matched control subjects , Hazen 's group detected a host of candidate compounds associated with cardiovascular risk . </p> The investigation revealed that when animals and people consume diets rich in choline ( a compound abundant in meat , poultry , and eggs ) , their gut microbes can transform the choline to trimethylamine . Trimethyl-amine is rapidly metabolized in the liver to trimethylamine iV-oxide ( TMAO ) @ @ @ @ @ @ @ @ @ @ accelerated thickening of the artery walls due to accumulation of cholesterol , compared with mice with lower TMAO levels . Hazen 's group further demonstrated that a cocktail of broad-spectrum antibiotics could suppress intestinal flora in mice and prevent production of atherogenic TMAO from the choline in ingested egg yolk lecithin. 13 </p> Hazen also reported that in a group of nearly 2,000 cardiovascular disease patients and controls , plasma TMAO levels predicted the future risk of cardiac events independent of traditional risk factors . 13 This suggests that a person 's microbiome profile could affect his or her heart-attack risk as much as or more than diet . It also could help explain why some people can get away with eating cholesterol-rich diets and others ca n't -- maybe those with gut flora that are poor at making TMAO are at less risk from eating high-fat diets , Hazen says . Although choline is an essential micro-nutrient crucial for brain development , many people may be getting too much of it , adds Hazen , in part because of the widespread use of lecithin in commercial baked goods to keep @ @ @ @ @ @ @ @ @ @ 10 other examples where researchers have used an untargeted " omics " screening approach -- such as that used by Hazen 's group -- to identify potential markers of disease , Rappaport says . " By accumulating the biologically active chemicals from these studies in a library of potential environmental hazards , future investigators will be able to determine whether these chemicals are involved in a host of diseases whose origins are currently unknown , " he says . </p> Managing the Data To truly characterize the exposome , however , these internal and external measurement modalities must be integrated . Although external exposures do n't lend themselves to the untargeted omics approach that has led to recent advances involving the internal exposome , Rappaport stresses that air and water pollution and other external factors , such as exercise and stress , contribute to human diseases and must be controlled . " This will require more and better methods for simultaneously monitoring multiple targeted external stressors and , in time , for combining external measurements with internal exposomes , " he says . </p> The ability to compare samples taken before @ @ @ @ @ @ @ @ @ @ obvious advantage to studying the exposome . Rappaport says investigators can move the science forward by developing prospective cohort studies that collect data on external stressors while also obtaining and storing blood or other biospecimens for future measurements of internal exposomes . </p> Accordingly , Nathaniel Rothman , head of molecular studies at the National Cancer Institute , says the 40 -- 50 general prospective cohort studies currently under way throughout the world have a variety of biological samples and history information available that scientists may be able to use in future exposome studies . Studies where repeat samples have been taken may prove especially useful , he notes . Birnbaum adds that the NIEHS maintains a huge library of biological specimens from studies conducted by intramural investigators . Suzanne Fitz-patrick , senior science advisor in the Office of the Chief Scientist at the Food and Drug Administration , points out that the samples collected during drug trials may be available for use by other researchers , too . Paul Elliott , chairman of epidemiology and public health medicine at Imperial College London School of Public Health , says the United @ @ @ @ @ @ @ @ @ @ for drug testing in the 2012 Summer Olympic Games to invest in what he called " exposomic " research . </p> Chirag Patel , a postdoctoral research fellow at the Stanford University School of Medicine , thinks the comprehensive connection of environmental factors to disease is now possible using the high-throughput analysis methods common in genome-based investigations . His proof of concept for such so-called environment-wide association studies used blood serum and urine samples from the National Health and Nutrition Examination Survey ( NHANES ) cohorts from 1999 through 2006 . In 2010 his group reported unexpected associations between type 2 diabetes and environmental exposures to heptachlor epoxide and ? -tocopherol. 14 They also found associations with polychlorinated biphenyls ( PCBs ) -- which have previously been linked to this form of diabetes -- and with pesticides . Investigators elsewhere have hypothesized that these chemicals might increase risk of obesity and metabolic diseases . </p> More recently , Patel 's group used the same techniques with NHANES data to screen for associations between environmental chemicals and blood lipids. 15 The preliminary findings suggest that higher levels of triglycerides and lower levels @ @ @ @ @ @ @ @ @ @ with higher concentrations of fat-soluble contaminants such as PCBs and dibenzofurans . Patel says these associations merit more investigation , although he also makes it clear that the potential for confounding and reverse causal biases needs to be investigated via longitudinal and followup studies . That is , because the studies are cross-sectional in nature , it is entirely possible that the associations are a consequence of disease rather than a cause . </p> In the longer-term future , Patel envisions a time when improvements in our ability to measure both the internal and external exposomes will enable investigators to assess hundreds to thousands of different factors in connection to specific diseases or health states . To use that information to discover associations with disease , he foresees that new analytical and informatics methods will be required . This was an issue in early genomics studies , and it eventually led to a proliferation of new statistical techniques and the field of bioinformatics , he points out . </p> Birnbaum , for one , is cautiously optimistic about the promise of environment-wide association studies . " Genetic factors are inherently less @ @ @ @ @ @ @ @ @ @ We may need some additional tools to deal with the environment . While bioinformatics is doing a great job now with the genetic information , I think we have a long way to go , and we need a lot more bioinformatics approaches and understanding to deal with the wealth of information that will come from the exposome . " </p> A person 's exposome is the sum total of the many exposure factors that fill the days , months , and decades of that person 's lifetime -- the exposures to chemicals , radiation , heat/cold , i noise , food , stress , and other environmental agents ; the health behaviors and activities ; and the unique profile of commensal bacteria that make an individual an individual . </p> Physical exertion is an important consideration when measuring exposure , because activity levels can affect how much of a pollutant a person inhales . In one study of different travel modalities , people riding bicycles inhaled more than 8 times as much air per minute as people driving cars and half again as much air as people who walked. 8 @ @ @ @ @ @ @ @ @ @ to exercise less -- rather , smart technology may someday advise travelers on small behavioral tweaks ( such as falling behind the traffic ahead or taking a slightly different route ) that could significantly reduce exposure to pollutants . </p> The microbiome is particularly important because it is a filter of perhaps our largest environmental exposure -- our diet . Moreover , different intestinal bacteria can convert contaminants into new forms that may be more or less bioavailable than the original compound . Variations in individuals ' microbiomes could help explain why different people have different levels of susceptibility to environmentally influenced diseases . </p> REFERENCES AND NOTES 1 . Wild C. Complementing the genome with an " exposome " : the outstanding challenge of environmental exposure measurement in molecular epidemiology . Cancer Epidemiol Biomar Prev 14(8)1847-1850(2005) ; http : **30;72823;TOOLONG EPI-05-0456 </p> 2 . Betts K. A study in balance : how microbiomes are changing the shape of environmental health . Environ Health Perspect 119(8):A340-A346(2011) ; http : **33;72855;TOOLONG </p> 3 . Emerging Technologies for Measuring Individual Exposomes workshop , Washington , DC , 8-9 Dec 2011 . Washington , @ @ @ @ @ @ @ @ @ @ : **63;72890;TOOLONG accessed 5 Mar 2012 </p> 4 . Kavanagh P , et al . Urinary arsenic species in Devon and Cornwal residents , UK . A pilot study . Analyst 123(1):27-29 ( 1998 ) ; http : **29;72955;TOOLONG </p> 5 . The World in 2011 : ICT Facts and Figures website , Geneva , Switzerland:lntemational Telecommunication Union ( 2011 ) . CTFactsFigures2011.pdf accessed 5 Mar 2012 </p> 6 . Sensans . Discover our SensPods website , Crolles , France Sensaris ( 2012 ) . Available : http : **44;72986;TOOLONG 5 Mar 2012 </p> 7 . NTP . Report on Carcinogens , 12th Edition . Research Triangle Park , NC:National Toxicology Program , U.S. Department of Health and Human Services ( 2011 ) . Available : http : //ntp.niehs.nih.gov/ntp/ roc/twelfth/rod2.pdf accessed 5 Mar 2012 </p> 8. de Nazelle A , et al . Improving health through policies that promote active travel a review of evidence to support integrated health impact assessment . Environ Intl 37(4)766-777 ( 2011 ) ; http : **41;73032;TOOLONG </p> 9 . Buck Louis GM , et al . Heavy meatals and couple fecundity , the LIFE Study @ @ @ @ @ @ @ @ @ @ 2012 </p> 10 . Schembri S , et al . MicroRNAs as modulators of smoking-induced gene expression changes in human airway epithelium . Proc Natl Acad Sci 106(7):2319-2324 ( 2009 ) ; http : **35;73075;TOOLONG </p> 11 . Spira A , et al . Effects of cigarette smoke on the human airway epithelial cell transcriptome . Proc Natl Acad Sci USA 101(27)10143-10148(2004) ; http : **35;73112;TOOLONG </p> 12 . Spira A , et al . Airway epithelial gene expression in the diagnostic evaluation of smokers with suspect lung cancer . Nature Med 13(3):361-366 ( 2007 ) ; http : **27;73149;TOOLONG </p> 13 . Wang Z , et al . Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease . Nature 472(7341)57-63 ( 2011 ) ; http : **32;73178;TOOLONG </p> 14 . Patel CJ , et al . An environment-wide association study ( EWAS ) on type 2 diabetes mellitus PLoS ONE 5(5):e10746 ( 2010 ) ; http : **41;73212;TOOLONG </p> 15 . Patel CJ , et al . Systematic evaluation of environmental factors : persistent pollutants and nutrients correlated with serum lipid levels . Int J Epidemiol ; http : **30;73255;TOOLONG online @ @ @ @ @ @ @ @ @ @ S. Betts has written about environmental contaminants , hazards , and technology for solving environmental problems for publications including FHP and Environmental Science &; Technology for more than a dozen years . </p> 
##4119660 Objectives . We better defined the distribution and determinants of coal workers ' pneumoconiosis ( CWP ) among US underground coal miners . </p> Methods . We obtained chest radiographs from the mobile unit of an enhanced surveillance program begun in 2005 by the National Institute for Occupational Safety and Health for underground coal miners . B Readers classified them for presence of pneumoconiosis . </p> Results . Miners from 15 states participated ( n = 6658 ) . The prevalence of CWP was higher in 3 states ( Kentucky , 9.0% ; Virginia , 8.0% ; West Virginia , 4.8% ) than in 12 other states ( age-adjusted risk ratio RR = 4.5 ; 95% confidence interval CI = 3.3 , 6.1 ) . Miners in these 3 states were younger and had less mining tenure , but advanced CWP ( category ? 2/1 ; RR = 8.1 ; 95% CI = 3.9 , 16.9 ) and progressive massive fibrosis ( RR = 10.5 ; 95% CI = 3.8 , 29.1 ) was more prevalent among them . Advanced CWP and progressive massive fibrosis were more prevalent @ @ @ @ @ @ @ @ @ @ irrespective of mining region , than among workers at larger mines . </p> Conclusions . Enhanced surveillance results confirmed the persistence of severe CWP among US coal miners and documented the health consequences of inadequate dust control for miners in parts of Appalachia and at smaller mines . ( Am J Public Health . 2012 ; 102:S279-S283 . ) </p> In the early 2000s , during the routine analysis of surveillance chest radiographs of underground coal miners , the National Institute for Occupational Safety and Health ( NIOSH ) began observing several aberrations in the frequency and severity of radiographic abnormalities among underground coal miners in the United States . Specifically , the overall prevalence of coal workers ' pneumoconiosis ( CWP ) appeared to be increasing , and NIOSH identified geographical clustering of CWP and observed rapid progression and increased disease severity , including progression to the most severe and fatal stage , progressive massive fibrosis ( PMF ) . 1 2 </p> In response to these occupational health findings , NIOSH , with support from the US Department of Labor 's Mine Safety and Health Administration , established and @ @ @ @ @ @ @ @ @ @ ECWHSP ) . ECWHSP , using a mobile examination unit in areas in which rapidly progressing CWP had been identified , 1-4 further assessed the initial surveillance findings , better defined the scope and magnitude of the problem and identified potentially remediable causes of the continuing development and progression of lung disease among underground coal miners . </p> Our focus was ECWHSP 's radiographic findings consistent with CWP among miner participants . Specifically , we examined the radiographic patterns among this group of at-risk miners and investigated potential explanatory factors such as mine location and size . </p> METHODS Characteristics of the ECWHSP have previously been described , 5 and information about the program , including methods and survey sites , is publicly available. 6 In brief , chest radiographs were taken in a mobile examination unit at or near mine sites and according to NIOSH-specified procedures , and they were classified by B Readers 7 for the presence , profusion , and type of lung parenchymal abnormalities consistent with pneumoconiosis using the 2000 revision of the International Labour Office 's International Classification of Radiographs of Pneumoconioses. 8 The mobile examination @ @ @ @ @ @ @ @ @ @ radiographs. 9 We restricted the analysis to the most recent radiograph available for each individual . All participants provided informed consent . </p> We defined the presence of CWP as a profusion of small pneumoconiotic opacities classified as 1/0 or greater or as PMF , according to the International Classification of Radiographs of Pneumoconioses. 8 We defined the presence of PMF as the recording of any large opacity interpreted as being consistent with massive fibrosis ( i.e. , Stage A , B , or C ) . On the basis of previous work , we included as a severity indicator r-type opacities , which have previously been used as a surrogate for silica exposure. 10 A radiograph was determined to show r-type opacities ( rounded opacities between 3 and 10 mm in diameter ) when the B Reader indicated r-type opacity as either primary or secondary . Multiple readings were available for each radiograph . To determine simple CWP profusion and presence of PMF , we used the NIOSH final determination , a summary measure derived from multiple classifications using a standardized procedure. 2 To evaluate small opacity size and shape @ @ @ @ @ @ @ @ @ @ . Data were available for September 2005 through October 2009 . Complete information on small opacity profusion , mine location , and employment size ( mine size ) was required for inclusion in the study . </p> We obtained mine name and location from each participating miner and determined the number of miners at the mine from reports submitted by mine operators to the Mine Safety and Health Administration . To calculate risk ratios , we categorized mine size by quartiles using the data for miners with CWP . In addition , we aggregated the data for the 3 states with highest CWP prevalence ( Kentucky , Virginia , and West Virginia ) and compared them with data for all other regions . This aggregation provided an approximately equal number of observations for both groupings . Because miner age is known to be associated with the presence and severity of CWP , we adjusted all disease risk ratios for miner age using log binomial regression . We compared median miner age using the Wilcoxon rank sum test . We used SAS version 9.1 ( SAS Institute , Cary , NC ) @ @ @ @ @ @ @ @ @ @ participants from 416 mines located in 15 states . The number of radiographs collected from miners in each state is presented in Figure 1 . The unadjusted prevalence of CWP varied by region and was highest in Kentucky ( 9.0% ) and Virginia ( 8% ) but did not differ between them ( P = .51 ) . CWP was found in 4.8% of the radiographs of miners from West Virginia , which significantly differed from its prevalence in Kentucky and Virginia ( risk ratio RR = 1.8 ; 95% CI = 1.4 , 2.3 ; P&lt; .001 ) . The prevalence of CWP in Kentucky , Virginia , and West Virginia as a group was 4 times as high as its prevalence in the other 12 states ( age-adjusted RR = 4.5 ; 95% CI = 3.3 , 6.1 ) , although miner age ( all miners ) was similar in both ( Table 1 ) . </p> In addition to the increased prevalence of overall CWP , significantly elevated age-adjusted risk ratios were associated with other outcomes , including a higher prevalence of advanced disease ( small opacity profusion @ @ @ @ @ @ @ @ @ @ = 3.9 , 16.9 ) , PMF ( RR = 10.5 ; 95% CI = 3.8 , 29.1 ) and r-type opacities ( RR = 7.7 ; 95% CI = 3.8 , 15.4 ) in Kentucky , Virginia , and West Virginia than in the 12 other states . </p> FIGURE 1-Prevalence of coal workers ' pneumoconiosis by state , sorted by prevalence : Enhanced Coal Workers ' Health Surveillance Program , 2005-2009 . </p> Mine Size We noted a decreasing trend in CWP prevalence as mine size increased ( Figure 2 ) . However , the effect of mine size was confounded with region because the distribution of mine size differed between regions . For example , Kentucky , Virginia , and West Virginia had significantly more mines with fewer than 100 employees ( 46.7% ) than did the 12 other coal mining states ( 15.1% ; P&lt;.001 ) . </p> We stratified the outcomes by region ( Kentucky , Virginia , and West Virginia or the 12 other states ) , which showed that the prevalences of CWP , PMF , r-type opacities , and small opacity profusion of @ @ @ @ @ @ @ @ @ @ and West Virginia were significantly associated with smaller mines , although not in a linear fashion . For example , the prevalences of r-type opacities and small opacity profusions of category 2 or higher were similar in mines with fewer than 40 miners , mines with 45-78 miners , and mines with 79-155 miners , but not in mines with more than 155 employees ( Table 2 ) . Small numbers of miners prevented a full analysis of all outcomes in the 12 other states , but the evidence showed a greater risk of overall CWP for miners in smaller mines ( RR = 6.8 ; 95% CI = 3.3 , 14.1 ) . </p> TABLE : TABLE 1-US Coal Workers ' Pneumoconiosis by Region : Enhanced Coal Workers ' Health Surveillance Program , 2005-2009 </p> Region Total No . CWP , No. ( % ) RR ( 95% CI ) Age of Miners , Years : All , Mean ( Median ) Age of Miners , Years : With CWP , Mean ( Median ) 12 states 3137 50 ( 1.6 ) Ref 47.2 ( 50.0 ) 53.8 ( 55.0 @ @ @ @ @ @ @ @ @ @ , 11.0 ) 45.1 ( 46.0 ) 50.4 ( 51.0 ) VA 648 52 ( 8.0 ) 6.0 ( 4.0 , 9.1 ) 47.4 ( 49.0 ) 51.1 ( 51.0 ) WV 1981 94 ( 4.8 ) 3.0 ( 2.1 , 4.3 ) 47.6 ( 51.0 ) 53.6 ( 53.0 ) KY , VA , and WV 3521 226 ( 6.4 ) 4.5 ( 3.3 , 6.1 ) 46.9 ( 50.0 ) 51.9 ( 52.0 ) </p> Note . CI = confidence interval ; CWP = coal workers ' pneumoconiosis ; RR = risk ratio . RR comparisons are given for Kentucky , Virginia , and West Virginia rather than prevalence of CWP as for the 12 other states included in the analysis ( AL , AR , CO , IL , IN , MD , NM , OH , PA , TN , UT , WY ) . </p> FIGURE 2-Prevalence of coal workers ' pneumoconiosis by mine size ( number of employees ) , unadjusted for age and region : Enhanced Coal Workers ' Health Surveillance Program , 2005-2009 . </p> Miner Age Consistent with the known epidemiology of @ @ @ @ @ @ @ @ @ @ severity . Miners working in the larger mines ( &gt; 155 miners ) were slightly older ( median age = 51 years ; median tenure = 24 years ) than miners from smaller mines ( ? 155 miners ; median age = 48 years ; median tenure = 23 years ) . The median tenure of miners with CWP was equivalent among those mining in Kentucky , Virginia , and West Virginia , but it was not equivalent with that of miners in the 12 other states ( 30 years ) . However , miners with CWP in Kentucky , Virginia , and West Virginia were younger ( median age = 52 years ) than miners in the other states ( median age = 55 years ; P = .01 ) , although overall the age of the workforce in the 2 regions was the same ( both median ages = 50 years ) . </p> DISCUSSION We present an updated picture of pneumoconiosis prevalence and severity in US underground coal miners as documented through active radiographic surveillance using a mobile examination unit stationed at or near working mines . We @ @ @ @ @ @ @ @ @ @ NIOSH-administered Coal Workers ' X-ray Surveillance Program . Our findings have confirmed recent reports that the prevalence and severity of pneumoconiosis is higher among miners in Kentucky , Virginia , and West Virginia than among miners in other parts of the United States. 1 3 4 10-12 </p> Irrespective of mining region , CWP is also more prevalent and severe among workers from smaller underground mines than among those from larger mines. 5 </p> Although mine size is associated with disease incidence , size per se is not the issue ; rather , the issue is factors associated with size . Small mine size brings with it the potential for limited knowledge of , and resources for , dust reduction and disease elimination . Although larger mines can employ trained industrial hygienists and purchase state-of-the-art dust suppression measures , small mines may not have such opportunities . </p> The ECWHSP results have shown that not only is the disease burden greater in smaller mines , but also miners with CWP in smaller mines are younger than those in larger mines . Similarly , in some regions of the country , disease @ @ @ @ @ @ @ @ @ @ finding that is not unique to NIOSH radiographic surveillance . Wade et al. 13 examined state compensation data between 2000 and 2009 and found that among compensated West Virginia miners , the average age at which PMF was recognized was younger than 53 years . In that study , PMF was observed in miners as young as 40 years . Given miners would have to have begun developing PMF at a younger age than when it was first identified , these findings are of great concern and demonstrate the need for further research to determine the causes . </p> Strengths and Limitations Our results have several strengths and limitations . Among the strengths are that the data were collected by a dedicated group of trained personnel in a single mobile examination unit using uniform equipment and procedures throughout the study period . All radiographs were interpreted by a minimum of 2 B Readers . All data were quality checked at the time of acquisition and verified by means of double data entry . Because participation in the monitoring program is voluntary , potential bias is a concern if those with radiographic @ @ @ @ @ @ @ @ @ @ to participate in the medical surveys . However , we are unaware of any evidence of differential participation between those with and those without radiographic evidence of pneumoconiosis . Meaningful differential participation by disease status seems unlikely : Recruitment efforts were directed at all miners , regardless of disease status . Moreover , miners are probably unaware that they have pneumoconiosis , at least in the less severe stages of the disease , because it often presents without symptoms . </p> TABLE : TABLE 2-Prevalence of US Coal Workers ' Pneumoconiosis and Progressive Massive Fibrosis and Indicators of Severity by Region and Mine Size : Enhanced Coal Workers ' Health Surveillance Program , 2005-2009 </p> KY , VA , and WV : Sample Size ( n = 3521 ) , No . KY , VA , and WV : No. ( % ) KY , VA , and WV : RR ( 95% CI ) Other Statesa : Sample Size ( n = 3137 ) , No . Other Statesa : No. ( % ) Other Statesa : RR ( 95% CI ) </p> CWP &lt; 40 miners 477 56 ( @ @ @ @ @ @ @ @ @ @ ( 5.9 ) 6.8 ( 3.3 , 14.1 ) 45-78 miners 728 67 ( 9.2 ) 3.7 ( 2.6 , 5.4 ) 210 3 ( 1.4 ) 1.8 ( 0.5 , 6.1 ) 79-155 miners 792 61 ( 7.7 ) 3.3 ( 2.3 , 4.9 ) 212 7 ( 3.3 ) 3.0 ( 1.3 , 6.9 ) &gt; 155 miners 1524 42 ( 2.8 ) Ref 2529 29 ( 1.2 ) Ref PMF &lt; 40 miners 477 7 ( 1.5 ) 2.3 ( 0.9 , 5.9 ) 186 2 ( 1.1 ) 45-78 miners 728 17 ( 2.3 ) 3.5 ( 1.6 , 7.5 ) 210 1 ( 0.5 ) 79-155 miners 792 10 ( 1.3 ) 2.0 ( 0.8 , 4.7 ) 212 0 ( 0 ) &gt; 155 miners 1524 11 ( 0.7 ) Ref 2529 1 ( 0.04 ) R-type opacityb &lt; 40 miners 477 14 ( 2.9 ) 5.1 ( 2.3 , 11.5 ) 186 4 ( 2.2 ) 45-78 miners 728 25 ( 3.4 ) 5.7 ( 2.8 , 11.9 ) 210 2 ( 1.0 ) 79-155 miners 792 25 ( 3.2 ) 5.6 ( 2.7 @ @ @ @ @ @ @ @ @ @ miners 1524 10 ( 0.7 ) Ref 2529 1 ( 0.04 ) Profusion ? 2/1 &lt; 40 miners 477 12 ( 2.5 ) 3.2 ( 1.5 , 7.0 ) 186 8 ( 4.3 ) 45-78 miners 728 20 ( 2.8 ) 3.3 ( 1.7 , 6.6 ) 210 1 ( 0.5 ) 79-155 miners 792 23 ( 2.9 ) 3.7 ( 2.7 , 11.6 ) 212 0 ( 0 ) &gt; 155 miners 1524 14 ( 0.9 ) Ref 2529 0 ( 0 ) Profusion ? 2/1 and PMF &lt; 40 miners 477 16 ( 3.4 ) 3.8 ( 1.9 , 7.5 ) 186 8 ( 4.3 ) 45-78 miners 728 29 ( 4.0 ) 4.2 ( 2.3 , 7.8 ) 210 1 ( 0.5 ) 79-155 miners 792 25 ( 3.2 ) 3.6 ( 1.9 , 6.7 ) 212 0 ( 0 ) &gt; 155 miners 1524 16 ( 1.1 ) Ref 2529 1 ( 0.04 ) </p> Note . CI = confidence interval ; CWP = coal workers ' pneumoconiosis ; PMF = progressive massive fibrosis ; RR = risk ratio . Mine size cutoffs were based on quartiles @ @ @ @ @ @ @ @ @ @ of ? 1/0 . </p> aAL , AR , CO , IL , IN , MD , NM , OH , PA , TN , UT , and WY . </p> bWe determined ft-type opacities from the most recent classification of the radiograph . We calculated risk ratios using log binomial regression and adjusted for miner age . RRs are not presented for indicators of severity for other states because of instability in the estimates owing to small numbers . </p> Findings from the ECWHSP were similar to those from the Coal Workers ' X-ray Surveillance Program and showed very similar tenure-specific prevalence of radiographic abnormalities ( data not shown ) . Our results were also quite consistent with published findings based on multiple data sources. 1 3 4 12-16 We should note that because the ECWHSP is restricted by federal mandate to currently employed coal miners , the findings likely represent the minimum burden of pneumoconiosis among miners and ex-miners in the areas sampled . </p> Conclusions Although the total magnitude of disease burden remains somewhat uncertain , what is known about the state of coal miner health in the @ @ @ @ @ @ @ @ @ @ 2005-2009 data from only the active surveillance program , identified 276 working miners with CWP , 77 with advanced disease , and 49 with PMF . As highlighted recently in commentaries by Loomis and Seaton , 17-19 in a contemporary mining industry , widely available dust control technologies should entirely protect miners from developing severe pneumoconiosis . Our results starkly emphasize the need for improved dust control measures and the continuing importance of active health surveillance for US coal miners . </p> Reprints can be ordered at http : //www.ajph.org by clicking the " Reprints " link . </p> This article was accepted August 21 , 2011 . </p> Acknowledgments We thank the Coal Workers ' Health Surveillance Program team , the B Readers , for their participation in this study and all of the miners who with their participation made the study possible . A. S. Laney acknowledges R. P. Fagan and I. C. Hall for their suggestions on literary voice and tone . </p> Human Participant Protection This study was conducted with the approval of the National Institute for Occupational Safety and Health . All participants provided informed consent @ @ @ @ @ @ @ @ @ @ Petsonk EL , Sokolow LZ , et al . Rapidly progressive coal workers ' pneumoconiosis in the United States : geographic clustering and other factors . Occup Environ Med. 2005 ; 62(10):670-674 . </p> 2 . Centers for Disease Control and Prevention . Pneumoconiosis prevalence among working coal miners examined in federal chest radiograph surveillance programs-United States , 1996-2002 . MMWR Morb Mortal Wkly Rep. 2003 ; 52(15):336-340 . </p> 3 . Centers for Disease Control and Prevention . Advanced cases of coal workers ' pneumoconiosis-two counties , Virginia , 2006 . MMWR Morb Mortal Wkly Rep. 2006 ; 55(33):909-913 . </p> 4 . Centers for Disease Control and Prevention . Advanced pneumoconiosis among working underground coal miners-Eastern Kentucky and Southwestern Virginia , 2006 . MMWR Morb Mortal Wkly Rep. 2007 ; 56(26):652-655 . </p> 5 . Laney AS , Attfield MD . Coal workers ' pneumoconiosis and progressive massive fibrosis are increasingly more prevalent among workers in small underground coal mines in the United States . Occup Environ Med. 2010 ; 67(6):428-431 . </p> 6 . National Institute for Occupational Safety and Health . Enhanced Coal Workers ' Health Surveillance @ @ @ @ @ @ @ @ @ @ //www.cdc.gov/ **42;10369;TOOLONG . Updated March 9 , 2011 . Accessed May 5 , 2011 . </p> 7 . National Institute for Occupational Safety and Health . Recommended practices for reliable classification of chest radiographs by B Readers . Available at : http : **44;10413;TOOLONG **32;10459;TOOLONG . Updated May 24 , 2011 . Accessed May 5 , 2011 . </p> 8 . International Labour Office . Guidelines for the Use of the ILO International Classification of Radiographs of Pneumoconioses . Geneva , Switzerland : International Labour Office ; 2002 . </p> 9 . Approval of roentgenographic facilities . 42 CFR &Sect; 37.42. ( 2002 ) . </p> 10 . Laney AS , Petsonk EL , Attfield MD . Pneumoconiosis among underground bituminous coal miners in the United States : is silicosis becoming more frequent ? Occup Environ Med. 2010 ; 67(10):652-656 . </p> 11 . Centers for Disease Control and Prevention . Changing patterns of pneumoconiosis mortality-United States , 1968-2000 . MMWR Morb Mortal Wkly Rep. 2004 ; 53(28):627-632 . </p> 12 . Suarthana E , Laney AS , Storey E , Hale JM , Attfield MD . Coal workers ' pneumoconiosis @ @ @ @ @ @ @ @ @ @ implementation of the 1969 Federal Coal Mine Health and Safety Act . Occup Environ Med. 2011 ; 68(12):908-13 . </p> 13 . Wade WA Petsonk EL , Young B , Mogri I. Severe occupational pneumoconiosis among West Virginia coal miners : 138 cases of progressive massive fibrosis compensated between 2000 and 2009 . Chest . 2011 ; 139(6) : 1458-1462 . </p> 14 . Centers for Disease Control and Prevention . Coal workers ' pneumoconiosis-related years of potential life lost before age 65 years-United States , 1968-2006 . MMWR Morb Mortal Wkly Rep. 2009 ; 58(50):1412-1416 . </p> 15 . National Institute for Occupational Safety and Health . Work-Related Lung Disease Surveillance Report 2007 . Morgantown , WV : Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health ; 2008 . DHHS ( NIOSH ) pub . no. 2008-143 . </p> 16 . National Institute for Occupational Safety and Health . Coal Mine Dust Exposures and Associated Health Outcomes : A Review of Information Published Since 1995 . Atlanta , GA : Centers for Disease Control and Prevention ; 2011 . Current Intelligence Bulletin 64 . DHHS @ @ @ @ @ @ @ @ @ @ Loomis D. Basic protections are still lacking . Occup Environ Med. 2010 ; 67(6):361 . </p> 18 . Loomis D. Time for global occupational health . Occup Environ Med. 2010 ; 67(3):145 . </p> 19 . Seaton A. Coal workers ' pneumoconiosis in small underground coal mines in the United States . Occup Environ Med. 2010 ; 67(6):364 . </p> By A. Scott Laney , PhD , A. Scott Laney are with the Surveillance Branch , Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health , Centers for Disease Control and Prevention , Morgantown , WV. 1095 Willowdale Road , Mail Stop HG900.2 , Morgantown , WV 26505-2888 ( e-mail : alaney@cdc.gov ) . ; Edward L. Petsonk , MD , Edward L. Petsonk are with the Surveillance Branch , Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health , Centers for Disease Control and Prevention , Morgantown , WV. ; Janet M. Hale , BS , Janet M. Hale are with the Surveillance Branch , Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health , Centers for Disease @ @ @ @ @ @ @ @ @ @ Wolfe , BS , Anita L. Wolfe are with the Surveillance Branch , Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health , Centers for Disease Control and Prevention , Morgantown , WV. and Michael D. Attfield , PhD , Michael D. Attfield are with the Surveillance Branch , Division of Respiratory Disease Studies , National Institute for Occupational Safety and Health , Centers for Disease Control and Prevention , Morgantown , WV . </p> 
##4119665 CPD </p> Employees who suffer from anxiety-driven panic attacks will require extra support in the workplace . Lisa du Plessis and Walter Brennan outline a case study that describes the type of help available and the involvement of occupational health in the treatment process . </p> When cable fitter John Jenkins had his first panic attack , he immediately thought that he was dying . Without any kind of warning , he developed pains in his chest and he could not breathe . He was working alone that day and quickly threw his tools into his van and was at the accident and emergency ( A &E); department within minutes . Investigations showed that Jenkins ' heart was fine ; he was medically sound . </p> However , when he had his second panic attack four days later , he was in the middle of a meeting with six colleagues . Again , he experienced chest pains , sweating and his whole body began to shake . He abruptly left the meeting and locked himself in the toilet for 15 minutes , before getting a taxi to A @ @ @ @ @ @ @ @ @ @ attack and was adamant that the hospital had got its diagnosis of " panic and stress " totally wrong . </p> His supervisor had taken note of Jenkins ' behaviour and when he asked him if he was ok , Jenkins put on an act and claimed that he was desperate for the bathroom and that he was feeling absolutely great . </p> The next day , Jenkins had his worst panic attack , while installing some cable in a trench in the middle of a busy shopping area . He was left gasping for breath and needed two of his colleagues to lift him out of the trench and lay him on the floor . An ambulance was called and he was taken to hospital once again . More exhaustive testing showed no physical pathology . However , he was becoming anxious , which was represented by : difficulty concentrating ; agitation ; frequent urination ; avoidance of meetings and colleagues ; loss of appetite ; irritability ; and insomnia . </p> Jenkins had always been a worrier ; even as a child he could recall worrying about his parents @ @ @ @ @ @ @ @ @ @ feared that danger was just around every corner . </p> He visited his GP , who asked him if he was experiencing any difficulties at home or at work , or if he was feeling stressed about any other matters . Jenkins explained that his job was always stressful and challenging , but he had always been able to cope with the pressure as he had worked for the company for almost 20 years . His GP diagnosed panic attacks and stress , offered him a prescription of oral medication for benzodiazepines and recommended that he come and see the counsellor based at the practice . </p> Both were refused by Jenkins and he continued to work . However , his colleagues began to notice that he had gone from being cheerful and funny to serious and barely communicative . Jenkins ' supervisor called him into his office to discuss his welfare and performance . Jenkins again put on an act of denying any problems before finally breaking down and weeping . He told his supervisor that he was convinced he was either about to die or go completely mad and @ @ @ @ @ @ @ @ @ @ his manager would tell his colleagues about his " breakdown " and that he would be labelled a " nutter " . </p> Jenkins ' supervisor reassured him that nobody would hear anything about this from him and that he was n't the only member of the team to experience emotional distress . </p> Jenkins found this information comforting . He was advised to visit the comapny 's occupational health adviser ( OHA ) . </p> Reluctantly , he met with the OHA , who explained how the occupational health department worked and that the service was ultimately about making him feel better and working well again . </p> Psychoanalysis As part of an overall assessment , the OHA conducted brief anxiety and depression questionnaires , known as psychometrics . </p> The PHQ-9 is a nine-item depression scale of the Patient Health Questionnaire . The PHQ-9 is a powerful tool for assisting primary-care clinicians in diagnosing depression , as well as selecting and monitoring treatment . </p> Jenkins made it clear that he would not take any medication and that he did not want to go off sick , as he @ @ @ @ @ @ @ @ @ @ and probably be sacked . </p> The OHA emphasised that mental health issues are far more common than many people believe and that the company was very much aware of how important employee wellbeing - both physical and emotional - is to the company . </p> Jenkins was asked by the OHA if he knew anything about cognitive behavioural therapy ( CBT ) . He admitted that he did not ; he also stated that he did not like the sound of it . The OHA gave Jenkins a brief outline of CBT . He then made a referral to a qualified cognitive behavioural psychotherapist approved by the company . </p> Jenkins was offered 10 sessions of cognitive behavioural psychotherapy and was diagnosed by the psychotherapist with panic disorder without agoraphobia . </p> What is panic disorder , with or without agoraphobia Panic disorder remains a major health problem and is associated with high levels of disability and medical care , compounded by difficulties accessing appropriate treatment ( Craske and Barlow , 2006 ) . </p> Initially called agoraphobia with panic attacks and later renamed panic disorder ( PD ) with @ @ @ @ @ @ @ @ @ @ , PD is one of the most researched anxiety disorders due to its high rate of lifetime prevalence ( about 5.1% of adults in the US ; anecdotally , this figure is estimated to be around 4% in the UK ) . </p> In order to be diagnosed with PD , a patient must have suffered recurrent and unexpected panic attacks over a minimum period of one month , followed by persistent concern about having additional attacks . Panic attacks are commonly accompanied by uncontrollable fear , worry about the implications of the attacks ( eg losing control or having a heart attack ) , or a significant change in behaviour relating to these symptoms . </p> Many people with the disorder attend A &E; believing that they have heart problems . According to the National Institute for Health and Clinical Excellence ( NICE ) : " For people who present with chest pain at A &E; services , there appears to be a greater likelihood of the cause being panic disorder if coronary artery disease is not present or the patient is female or relatively young " ( NICE , @ @ @ @ @ @ @ @ @ @ is one of the major orientations of psychotherapy ( Roth et al , 2005 ) and represents a unique category of psychological intervention because it derives from cognitive and behavioural psychological models of human behaviour that include , for instance , theories of normal and abnormal development , and theories of emotion and psychopathology . </p> Cognitive therapy is based on the clinical application of the more recent , but now also extensive , research into the prominent role of cognitions in the development of emotional disorders . </p> The approach usually focuses on difficulties in the here and now , and relies on the therapist and client developing a shared view of the individual 's problem . </p> This leads to identification of personalised , usually time-limited , therapy goals and strategies , which are continually monitored and evaluated . </p> The treatments are inherently empowering in nature , the outcome being to focus on specific psychological and practical skills ( eg reflecting on and exploring the meaning attributed to events and situations and re-evaluation of those meanings ) that are aimed at enabling the client to tackle their problems @ @ @ @ @ @ @ @ @ @ utilisation of such skills is seen as the main goal , and the active component in promoting change with an emphasis on putting what has been learned into practice between sessions ( " homework " ) . </p> Thus , the overall aim is for the individual to attribute improvement in their problems to their own efforts , in collaboration with the psychotherapist . Cognitive and/or behavioural psychotherapists work with individuals , families and groups . </p> Patient details and referral Jenkins is a 40-year-old married man with a 17-year-old son and works full time as a cable fitter for a large telecommunications company . The referrer reported that Jenkins had recently experienced panic attacks while at work and this was impairing his psychological wellbeing and occupational functioning . </p> Presenting problems of the patient Jenkins reported that he was experiencing symptoms of panic attacks , anxiety and worry , which he felt were spontaneous and started four to six weeks earlier . </p> Broad cognitive behavioural assessment and mental state examination Jenkins ' assessment and formulation of his problems took place over two appointment sessions . He attended the psychotherapy @ @ @ @ @ @ @ @ @ @ interview and self-report questionnaires . </p> The assessment and examination considered issues such as initial observations about Jenkins and his environment , including the relationship with his family and colleagues . </p> His " affect " ( mood ) was assessed along with how his anxiety physiologically affected him , including feelings of muscle tension , headaches and tingling in his fingers . </p> The behavioural component of his condition meant that Jenkins was worrying excessively ; he would not work alone in case he had another attack and he kept seeking reassurance from his colleagues and his wife when anxiety symptoms increased . </p> An assessment of Jenkins ' cognition showed good attention and concentration during both assessment and treatment , though he made statement such as : " If I do n't worry , something bad might happen to my son . " </p> Treatment component Jenkins attended 10 sessions of CBT and completed the full course . </p> * Session one </p> This included setting specific treatment goals ( these should be specific goals that can be measured ) and formulating Jenkins ' problem in a cognitive behavioural @ @ @ @ @ @ @ @ @ @ </p> * Regulate sleep pattern - sleep from around 11pm until 7am , with less than one hour of wakeful periods in the night . * Achieve a healthy lifestyle , ie eating and exercise - attend the gym three times per week on the way to work and eat less fatty/ high-calorie foods . * Socialise with friends without worrying about son and experiencing an anxiety rating of 3/10 or less . * Reduce/stop panic attacks . * Reduce worrying to no more than 30 minutes daily . * Feel happier - rate mood as at least 6/10 four days per week . * Stop seeking reassurance for panic/anxiety symptoms ( no attending hospital or asking his wife/ colleagues for reassurance when feeling anxious ) . * Attend and engage in work meetings with an anxiety rating of no more than 3/10. * Attend lone-worker jobs and complete with an anxiety rating of no more than 3/10 . Clark 's model of panic ( Clark , 1986 ) was used to diagnose Jenkins ' problem . </p> * Session two </p> This involved socialisation to the CBT model and psycho-education @ @ @ @ @ @ @ @ @ @ educate the client and help them gain an understanding about how CBT actually works and treats problems . It is also where the client is made aware that homework will be given at each session and how CBT is collaborative . Psychological education was focused around panic disorder , how it develops and why is does not go away . It is very important to revisit the formulation to highlight what behaviours and thoughts maintain the problem . Jenkins became aware that he had a fear of fear . A diary was introduced for Jenkins to record panic symptoms . </p> * Session three </p> This session focused on anxiety management . It is important that when treating panic disorder , Jenkins should really understand how the survival/fight/flight response works . </p> It is a lesson in human biology relating to the client 's problems . This helps with misinterpretation of anxiety symptoms that are a key factor in panic disorder . Jenkins was able to see how his body was preparing to run or fight as he prepared for what he thought was a dangerous situation . </p> * Session @ @ @ @ @ @ @ @ @ @ which is a behaviour technique used in CBT . It refers to carrying out exercises that bring about the physical sensations of a panic attack , such as hyperventilation and high muscle tension . </p> This was effective in provoking a wide range of panic-like sensations , such as dizziness , feeling hot , increased heart rate , tightness in the chest and visual changes . It was useful to challenge misinterpretations of these sensations , such as heart attack or fainting , and for building tolerance of anxious feelings . </p> * Sessions five to seven </p> In these sessions of relaxation and exposure , Jenkins was taught how to utilise a relaxation technique called progressive muscle relaxation , where specific muscle groups are tensed and relaxed . </p> * Sessions eight to nine </p> In these cognitive restructuring sessions , Jenkins was educated about thoughts/beliefs and thinking and how this affected his behaviour and mood . Within the session , unhelpful thinking habits ( cognitive distortions ) were reviewed . This enabled the identification of several of these habits that Jenkins experienced on a regular basis . </p> * @ @ @ @ @ @ @ @ @ @ relapse by identifying the helpful changes that he made during therapy in all areas ( thoughts , feeling , behaviours , physical sensations and relationships ) . It also identified signs of relapse and what to do to prevent symptoms returning or how to treat Jenkins ' symptoms quickly , similar to an action plan of what to do . </p> Conclusion Jenkins was initially resistant to CBT and often the first five minutes of each session would be about restoring his belief in the treatment . Eventually , his gradual improvement enabled him to meet his treatment goals and his psychometric scores reached sub-clinical levels . </p> The occupational health team at Jenkins ' company supported him as he gradually returned to work over a three-month period . </p> One of the most important areas of growth for Jenkins was the knowledge and confidence that while anxiety could not be prevented , it could now be understood and managed . </p> The OHA trained to deliver the Mental Wealth Programme ( Brennan , 2005 ) and introduced it as a general mental wellbeing option for employees within the company to @ @ @ @ @ @ @ @ @ @ staff feeling well mentally . </p> Jenkins was able to return to all of his duties after six months and continued to utilise the skills acquired as part of his homework during CBT . </p> His employers also ran a training course on the Health and Safety Executives six Management Standards ( Health and Safety Executive , 2004 ) for dealing with stress for managers and supervisors . </p> Author note : the name and occupation of the case-study subject have been changed . </p> CPD Continuing Professional Development Study Time 3hrs* </p> Our learning for life service helps you use the journal for CPD-related private study . One article in each issue is accompanied by a set of questions and answers . These have been devised by education and healthcare consultant Greta Thornbory and are designed to help you reflect in a structured manner on what you have learnt . </p> *Some of the articles in our continuing professional development section display a STUDY TIME logo . The number displayed beside this is the number of hours that we estimate reading and reflecting on the article itself and any recommended @ @ @ @ @ @ @ @ @ @ CPD quiz : Mental health case study Lifelong learning and continuing professional development ( CPD ) are the processes by which professionals , such as nurses , develop and improve their practice . </p> There are two ways to address your CPD : formally , by attending courses , study days and workshops ; or informally , through private study and reflection . </p> Reading articles in professional journals is a good way of keeping up to date with what is going on in the field of practice , but reflecting on what you have learnt from the articles is not always easy . </p> These questions are designed to help you identify what you have learnt from studying the article on the previous three pages . They will also help you to clarify what you can apply in practice and what you need to explore further . </p> 1 Which of the following was NOT one of Jenkins ' panic attack symptoms ? </p> a ) Agitation and irritability b ) Avoidance of meetings and colleagues c ) Urinary retention d ) Loss of appetite </p> 2 What psychometric test @ @ @ @ @ @ @ @ @ @ b ) HAD c ) LSAS d ) PHQ-9 </p> 3 How many sessions of cognitive behavioural therapy was Jenkins offered ? </p> a ) 6 b ) 8 c ) 10 d ) 12 </p> 4 What was the psychotherapist 's diagnosis ? </p> a ) Panic disorder without agoraphobia b ) Panic disorder with agoraphobia c ) Agoraphobia with panic attacks d ) Anxiety and depression </p> 5 What is the active component in promoting change between sessions ? </p> a ) Prep b ) Homework c ) Legwork d ) Groundwork </p> 6 Which of the following do cognitive behavioural therapists NOT work with ? </p> a ) Individuals b ) Families c ) Groups d ) Babies </p> 7 When did Jenkins ' symptoms begin ? </p> a ) One week earlier b ) Two to four weeks earlier c ) Four to six weeks earlier d ) Three months earlier </p> 8 In the context of psychotherapy what does the term " affect " mean ? </p> a ) Mood b ) Result c ) Influence on others d ) Influence on the environment </p> 9 @ @ @ @ @ @ @ @ @ @ to carry out exercises that bring about the physical sensations of a panic attack ? </p> a ) Inception b ) Role play c ) Interoceptive d ) Neurophenomenology </p> 10 What programme was the OH adviser trained to deliver ? </p> a ) Mental Wealth b ) Healthy Lifestyle c ) Health Awareness d ) Mental Awareness </p> ANSWERS </p> * c - One is much more likely to have frequency than retention . * d - These are all different psychometric tests . Take some time to explore each one and its value for use in an OH setting . * c * a * b - All of these words were defined in a thesaurus as relating to " homework " ; the key to successful cognitive behavioural therapy is the work the individual has to do between sessions with the therapist. * d * c * a * c - Explore these different words and their relevance to cognitive behavioural therapy and other psychotherapies. * a -You can read Walter Brennan 's 2005 article at : **75;110966;TOOLONG The Mental Wealth course is available at : www.oliverbrennan.co.uk Online @ @ @ @ @ @ @ @ @ @ a charity that helps people to take charge of their mental health . It provides information and advice , training programmes , grants and services through a network of local Mind associations . The charity carries out it 's work to help people who experience mental distress to live full lives and play their full part in society . </p> * **70;111043;TOOLONG </p> The Centre for Mental Health aims to help create a society in which people with mental health problems enjoy equal chances in life to those who do not suffer from mental ill health . It focuses on criminal justice and employment , with supporting work on broader mental health and public policy . </p> * www.mindfulemployer.net </p> Developed , led and supported by employers , the Mindful Employer initiative is aimed at increasing awareness of mental health at work and providing support for businesses in recruiting and retaining staff . It provides some useful resources to signatories such as the " Line Managers ' Resource " , which offers managers comprehensive guidance on dealing with employees with mental health issues . It also has a section on cognitive @ @ @ @ @ @ @ @ @ @ This is the website for the British Association for Cognitive and Behavioural Therapies . It has lots of information about CBT and other therapies , as well as details about training courses , events , etc . </p> * **59;111147;TOOLONG </p> This website gives access to a fact sheet on CBT from the Royal College of Psychiatrists . </p> * **31;111208;TOOLONG </p> This website provides more information on the Health and Safety Executive Management Standards on stress . </p> * www.mhfaengland.org </p> Mental Health Fist Aid ( MHFA ) England was developed and launched in 2006 by the Department of Health . In September 2009 , it became registered as a community interest company ( registration no. 7021392 ) . The company is limited by guarantee Lie it has no shareholders ) and is at the heart of a network that is growing across the UK . It is also part of an expanding international movement around the world , which currently involving 16 countries . A community interest company ( CIC ) is one that " seeks to operate for the benefit of the community rather than for its owners @ @ @ @ @ @ @ @ @ @ the owners of the company or other such group . All assets and profits must be used for the community that is specified . This can be through allocating profits or providing services . ALL CIC 's must meet a ' Community Interest Test ' to become one . " The community interest that is core to MHFA England is to " increase mental health Literacy of the whole population " . </p> * www.smhfa.com </p> This is the website for MHFA Scotland . </p> * www.mhfa-wales.org.uk </p> This is the website for MHFA Wales . </p> References &gt; American Psychiatric Association ( 1980 ) . Diagnostic and Statistical Manual of Mental Disorders . Third edition . Washington , DC . </p> &gt; BABCP ( 2012 ) . British Association of Behavioural and Cognitive Psychotherapies . </p> &gt; Bienvenu OJ ( 2006 ) . " Lifetime prevalence of panic disorder is about 5% in the USA " . Evidence-Based Mental Health ; 9 ; 114 . </p> &gt; Clark DM ( 1986 ) . " A cognitive model of panic " . Behavior Research and Therapy . 24:461-470 . </p> &gt; @ @ @ @ @ @ @ @ @ @ mind " . Occupational Health ; February . </p> &gt; Craske MG , Barlow DH ( 2006 ) . Mastery of Your Anxiety and Panic : Therapist Guide . Fourth edition . New York , NY : Oxford University Press . </p> &gt; Kroenke K. Spitzer RL ( 2002 ) . " The PHQ-9 : a new depression and diagnostic severity measure " . Psychiatric Annals ; 32:509-521 . </p> &gt; National Institute for Health and Clinical Excellence ( 2007 ) . Clinical Guideline 22 ( amended ) : " Anxiety : management of anxiety ( panic disorder , with or without agoraphobia , and generalised anxiety disorder ) in adults in primary , secondary and community care " . </p> &gt; Roth A , Fonagy P ( 2005 ) . What Works for Whom : A Critical Review of Psychotherapy Research . Second edition . The Guildford Press , London . </p> By Lisa du Plessis and Walter Brennan </p> Lisa du Plessis is a BABCP-accredited cognitive behavioural psychotherapist and is the director of Sunflower CBT in St Albans , Hertfordshire . </p> Walter Brennan is a training consultant and @ @ @ @ @ @ @ @ @ @ Oliver Brennan Training Ltd . </p> 
##4119666 Postsecondary Education </p> Using the Summary of Performance to Enhance Transition Planning The Individuals With Disabilities Education Act requires that local education agencies provide a transition summary document to all special education students who graduate with a regular diploma or reach the maximum age for services . Although state compliance with this requirement is almost universal , is this process being used effectively to enhance postschool outcomes for students with disabilities ? There is an array of practices that school district and state education agency personnel can implement to make this document more helpful to students , bridging the " documentation disconnect " between secondary school and postsecondary education and employment , enhancing self-determination skills , and fostering improved adult success . </p> When students with disabilities transition to postsecondary environments , such as education or employment , they move from the mandates of the Individuals With Disabilities Education Act ( IDEA , 2006 ) to the protections of the ADA Amendments Act of 2008 ( ADAAA , 2009 ) and Section 504 of the Rehabilitation Act of 1973 ( Section 504 , 2006 ) . To receive @ @ @ @ @ @ @ @ @ @ and Section 504 require that an individual document the existence of a disability that substantially limits a major life function . Postsecondary programs and employers can -- and do -- set varying standards in relation to the comprehensiveness and the recency of this documentation . Traditionally , such documentation has comprised evaluations conducted as part of the special education eligibility determination and updates as required under the IDEA . </p> However , IDEA regulations do not require routine testing and evaluation . If the individualized education program ( IEP ) team determines that " no additional data are needed to determine whether the child continues to be a child with a disability , and to determine the child 's educational needs " ( 34 C.F.R. 300.305 d1 ) , formal assessments for reevaluation may be deemed unnecessary . Recently , there has been increasing focus on the use of informal assessments ( e.g. , response to intervention , curriculum-based assessment ) , limiting the use of traditional psychoeducational evaluations . In addition , IDEA clearly indicates that an " exit evaluation " for students leaving high school is not required ( @ @ @ @ @ @ @ @ @ @ , 2011 ) . These changes may result in students transitioning to postsecondary programs with outdated documentation of their disability , which may negatively impact their eligibility for services and accommodations in postsecondary environments . </p> However , IDEA does offer the local education agency ( LEA ) a potentially powerful tool to help students bridge this gap as they shift from secondary to postsecondary environments : the summary of performance ( SOP ) . IDEA requires LEAs to develop a summary statement of " academic achievement and functional performance " for students with disabilities who are exiting special education due to graduation or reaching the maximum age of eligibility for services , and this statement must include " recommendations on how to assist the child in meeting the child 's postsecondary goals ( 34 CFR 300.305e 3 ) ) . This type of information is particularly important because psychoeducational evaluations do not address postsecondary expectations . Although this legislation specifies minimum requirements , it is critical that teachers , families , agencies , and most importantly the students , work collaboratively to create a comprehensive SOP that will lead to @ @ @ @ @ @ @ @ @ @ leave the substantive details of the SOP to states and local school districts , and there are significant variations in how states and districts operationalize the SOP . Despite these variations , the true spirit of these tools must both reflect best practice and meet the needs of students with disabilities and their families to ensure a successful transition . </p> Current Status of SOP Implementation The National Association of State Directors of Special Education published a policy analysis on state education agency ( SEA ) response to the SOP ( Sopko , 2008 ) . The study found that 30 SEAs had developed an SOP form , but not all required LEAs to use their form . ( The study did not detail the contents of the form created by the states . ) Madaus et al . ( 2011 ) recently reviewed SEA web sites to identify the elements included in each state 's SOP form . Of the 43 state forms examined , 88% were in compliance with the three core SOP requirements specified in IDEA 2004 ( i.e. , a statement of academic achievement , a statement @ @ @ @ @ @ @ @ @ @ the student meet postsecondary goals ) . Although this data is generally encouraging , it is unfortunate that seven of the states did not have SOP forms that met the minimum requirements of IDEA -- and only about half of the states ' SOPs could be described as comprehensive . In addition , both Sopko ( 2008 ) and Madaus et al . ( 2011 ) have noted that many states are not mandating LEAs to use the state-approved form . This raises questions about the utility of the SOPs being used in districts and schools throughout the country . </p> Precisely because the IDEA regulations do not specify what should be included in an SOP , the National Transition Assessment Summit ( NTAS ) was convened in 200S . This group included representatives from many national disability organizations including secondary , postsecondary , state departments of education , local education agency personnel , and consumers . NTAS developed a model SOP intended to direct the field toward best practice for this document ( NTAS , 2005 ; Shaw , Madaus , &; Dukes , 2010 ) . The Nationally Ratified @ @ @ @ @ @ @ @ @ @ been endorsed by the Council for Exceptional Children ( CEC ) , several of its divisions , and other national organizations such as the Council for Learning Disabilities , the Higher Education Consortium for Special Education , and the Learning Disability Association of America . NTAS encouraged SEAs and LEAs to adopt the template or adapt it to meet their specific needs . Madaus and colleagues ' ( 2011 ) recent analysis of 43 states revealed 21% of the states have adopted the NTAS model SOP template and attributed their form to this source ; 40% of the states fulfill the NTAS template guidelines such as attaching disability documentation . </p> The U.S. Department of Education , in the regulatory comments accompanying the 2004 reauthorization of IDEA , noted that state and local officials should have the flexibility to determine appropriate content for a student 's summary , which must be based on the student 's individual needs and postsecondary goals ( 34 C.F.R. Sec. 300.305e 3 ) . However , this flexibility must be balanced with the need to assure that students with disabilities , upon leaving high school , @ @ @ @ @ @ @ @ @ @ outcomes . States or districts that do not employ a comprehensive SOP should consider reviewing and implementing model forms from other states or districts ( see box , " SOP Resources " ) . </p> Implementing and Developing the SOP Although not stated in the IDEA regulations , it is recommended that the SOP be the responsibility of the IEP team , just as are other transition planning components ( NTAS , 2005 ) . The IEP team should determine who should be involved in developing the initial SOP draft , set a timeline for completion , and approve the final SOP . Although the SOP may be the culminating event in the student 's transition process , it can also be developed over time with meaningful input from the student . </p> If the SOP is developed as an element of transition planning across time , consider the following recommendations : </p> * Review the SOP at regular intervals with the student ( e.g. , during annual IEP review ) to foster an understanding of progress over time and future transition needs to be addressed . </p> * Develop an @ @ @ @ @ @ @ @ @ @ necessary transition assessment data -- and develop a timeline for accumulating this information . If the contents of the portfolio are transferred annually to a working SOP , it promotes integration and use of the results . </p> * Whenever possible , have the student lead the SOP discussion during transition IEP meetings to further promote self-determination . </p> * Involve various stakeholders ( e.g. , student , family , special and general educators , school psychologist , school counselors ) in developing the SOP to promote a team approach . </p> Madaus et al . ( 2011 ) reported that many LEAs have implemented productive approaches to distributing the SOP to students . Some have formal exit interviews where the contents of the SOP are discussed and the document is given to the student . Others give the SOP to the student at a face-to-face meeting or send it by mail . Regardless of how this is accomplished , it is critical that the SOP process involve the student . </p> The Importance of the SOP The SOP should be viewed as a critical step in a student 's transition @ @ @ @ @ @ @ @ @ @ to be in compliance with IDEA . A well-constructed and thorough SOP can serve as a teaching tool that provides students with an opportunity to practice self-determination and to develop an awareness of their disability , strengths , and needs ( Shaw , 2009 ) . It can be part of a deliberate and comprehensive transition plan that is initiated with a determination of the student 's postsecondary goals which are delineated from and based upon age-appropriate transition assessments , as mandated by IDEA . The student 's secondary curriculum and transition plan should then be targeted toward reaching these goals . Ongoing data collection , both formal and informal , helps to measure progress toward meeting postsecondary goals , and it is precisely this data that provides the foundation upon which the SOP is developed ( Madaus &; Shaw , 2007 ) . </p> The SOP addresses two audiences . The first is the student ; the SOP can serve as a tool that students use to help access postsecondary supports under the ADAAA and Section 504 . To enhance the value of the SOP in this regard , it @ @ @ @ @ @ @ @ @ @ understandable , and useable document that facilitates successful postschool student outcomes in terms of employment and/or postsecondary education . It should describe strengths , skills , needs , and strategy use in language that promotes the provision of appropriate postschool accommodations . In order to capitalize on the potential use of the document as a student-led tool , the narrative should be written in positive , person-centered language . Students , in collaboration with secondary professionals , can begin preparing the SOP during their first year of high school and update it every year , so that the SOP becomes part of a student-driven transition portfolio . Alternatively , the SOP can be used as a senior-year capstone experience in which the student participates in its completion as part of a graduation project . Self-determination should play a central role in whatever SOP approach is chosen . Self-determination can be reflected in the process by having the student focus on meaningful postsecondary goals , reinforcing student knowledge of the disability , its impact on performance as well as strengths , and involving the student in identifying accommodations that have improved school @ @ @ @ @ @ @ @ @ @ are a potential second audience for the SOP . A well-constructed and comprehensive SOP can provide postsecondary professionals with current , comprehensive , and meaningful information about the student 's strengths and potential accommodations required ( Madaus &; Shaw , 2007 ) . The ADAAA has changed the emphasis in postsecondary disability documentation from a determination of disability status to a focus on the need for supports and accommodations based on the functional impact of the disability . An SOP that indicates what accommodations , compensatory services , and supports have been effective to ameliorate deficits will be particularly useful to postsecondary education disability personnel and employers ( Shaw , Keenan , Madaus , &; Banerjee , 2010 ) . More important , by effectively implementing this mandate , school personnel will address critical accountability issues related to employment and postsecondary education outcomes ( Shaw , Madaus et al. , 2010 ) . At the postsecondary level , the student alone is responsible for self-identification as someone with a disability , presenting documentation to support that claim and requesting postschool accommodations from employers or education personnel . A comprehensive SOP is @ @ @ @ @ @ @ @ @ @ SOP Part 1 : Background Information The first section of the SOP , following the NTAS model SOP template ( see Table 1 ) , should include the student 's demographic information , identified disability , and date of diagnosis . The most recent evaluation data should be attached to the completed SOP ; this is particularly important for students going on to college . The institution 's disability services office may require evaluation data to determine eligibility under ADAAA ( Dukes , 2010 ) . </p> Part 2 : Student 's Postsecondary Goals Students and their families should lead the determination of postsecondary goals and dictate what information will be highlighted in sections of the SOP . By law , the goals should address education or training , employment , and independent living as appropriate ( Kochhar-Bryant &; Izzo , 2006 ) . The goals included in Part 2 of the SOP are a reflection of the measurable postsecondary goals the student and family articulated during the IEP transition assessment process ( Dukes , 2010 ) . </p> Part 3 : Summary of Performance This section is designed to include @ @ @ @ @ @ @ @ @ @ functional skills . It is critical that this section of the SOP highlight the student 's strengths , needs , preferences , and interests . An SOP that merely repeats the test scores that are included on the attached disability documentation loses a valuable opportunity to explain the student 's strengths and needs . Data included in this section of the SOP should reflect the postsecondary goals previously specified . For example , if the student and family have indicated employment as a goal , then the vocational , employment , and career areas become particularly important , as well as social , environmental access , and mobility areas . A wide array of formal and informal data sources should be used in Part 3 to highlight the student 's strengths and needs . </p> Part 4 : Recommendations to Assist the Student in Meeting Postsecondary Goals This section highlights suggestions for accommodations , adaptive devices , assistive services , compensatory strategies , or support services for the purpose of enhancing access to postsecondary education or employment . Be especially careful when completing this section . Employers and postsecondary institutions are @ @ @ @ @ @ @ @ @ @ and students and families need to be aware that the suggested accommodations and supports are only recommendations . Postsecondary agencies make independent decisions based on situation-specific variables in their respective settings ( i.e. , speed is not an issue for that job so extended time is not needed , or a different accommodation is being used to ameliorate that deficit ) . </p> Part 5 : Student Input Encouraging students to participate in developing the SOP can foster understanding of their disability and their need for supports and accommodations . It also promotes self-determination as we specifically seek to " hear " the student 's voice in the development of the SOP document . Given that self-determination is associated with success in both employment ( Wehmeyer &; Palmer , 2003 ) and postsecondary education ( Field , Sarver , &; Shaw , 2003 ) , this is a vital part of the SOP process . Remember , it is the student 's responsibility to communicate needs to service providers in post high school settings . Postsecondary personnel will be particularly interested in the student 's perspective given that he or she @ @ @ @ @ @ @ @ @ @ point of contact when requesting postschool supports . </p> Final Thoughts The SOP is designed to apply to students with a range of disabilities transitioning to diverse postsecondary environments . In some cases , the data included will be curriculum-based , and supplemented with formal evaluations . In other cases , the opposite may be true . For example , for students transitioning to higher education , the Part 3 summary of academic and cognitive skills may be the most important portion of the document . For those seeking employment , consideration of the vocational , social , and independent living skills categories in that same section may be the most critical in the transition to adult life . This information has often not been available in traditional psychoeducational evaluations . </p> A comprehensive SOP is not a new set of evaluations and assessment data ; it is a summary of existing data and of performance in academic and functional areas ( Madaus , Bigaj , Chafouleas , &; Simonsen , 2006 ) . The SOP offers students , in collaboration with high school professionals , the opportunity to summarize current @ @ @ @ @ @ @ @ @ @ that have assisted the student in the secondary environment . This discussion of accommodations and modifications should focus on those that have been used effectively . A comprehensive SOP with this sort of information will provide both employers and service providers in postsecondary institutions insight into the student 's present level of performance and functional limitations that can be used to promote postschool success . </p> Summary of Performance ( SOP ) Resources * The U.S. Department of Education 's IDEA web site includes a questions-and-answers page related to secondary transition , with information specifically about the SOP . Visit http : //idea.ed.gov &gt; Part B ; enter " secondary transition " into the Search box . </p> * The National Secondary Transition Technical Assistance Center web site ( http : //www.nsttac.org/ ) has video resources , webinars , FAQs , references , and a bibliography . </p> * The Vermillion Association for Special Education 's web site ( http : **35;133367;TOOLONG ) includes a white paper rationale for the purpose of a standardized SOP , a PowerPoint presentation , and a standardized , fillable SOP ( Word document ) with @ @ @ @ @ @ @ @ @ @ </p> * The North Dakota Department of Public Instruction 's web site ( http : **49;133404;TOOLONG ) offers an SOP Fact Sheet , a sample SOP , and a sample of a completed SOP . There are also directions for completing the form . </p> * PRO-ED 's Summary of Performance System ( Patton , Clark , &; Trainor , 2009 ; visit http : //www.proedinc.com and enter SOPS into the search engine ) is a computerized system for developing a comprehensive and appropriate SOP . </p> * The Oklahoma State Department of Education has an example of an SOP that features student involvement at http : **73;133455;TOOLONG </p> * The National Collaborative on Workforce and Disability 's Assessment Quick Reference Guide , which describes formal and informal assessments , standardized testing , and the process of collecting transition information , is available at http : **54;133530;TOOLONG </p> Table 1 . Components of the Summary of Performance ( SOP ) pqp Note . The NTAS model SOP can be accessed at http : **34;133586;TOOLONG ? Section = Home &CONTENTID; = 6031 &TEMPLATE; = /CM/ContentDisplay.cfm &CAT; = none </p> References ADA Amendments @ @ @ @ @ @ @ @ @ @ to be codified at 42 U.S.C. 12101 ( 2009 ) . </p> Dukes , L. L. , III . ( 2010 ) . Gathering data to determine eligibility for services and accommodations . In S. F. Shaw , J. W. Madaus , &; L. L. Dukes III ( Eds . ) , Preparing students with disabilities for college success : A practical guide for transition planning ( pp. 167-201 ) . Baltimore , MD : Brookes . </p> Field , S. , Sarver , M. , &; Shaw , S. ( 2003 ) . Self-determination : A key to success in postsecondary education students with learning disabilities . Remedial and Special Education , 24 , 339-349. http : **28;133622;TOOLONG 5030240060501 </p> IDEA Regulations , 34 C.F.R. 300 ( 2006 ) . </p> Individuals With Disabilities Education Act of 2004. 20 U.S.C. 1400 et seq . ( 2006 ) . </p> Kochhar-Bryant , C , &; Izzo , M. ( 2006 ) . Access to post-high school services : Transition assessment and the summary of performance . Career Development for Exceptional Individuals , 29 , 70-89. http : **34;133652;TOOLONG 0020601 </p> Leconte @ @ @ @ @ @ @ @ @ @ , vocational , and transition assessment : Implications for the summary of performance . Career Development for Exceptional Individuals , 29 , 114-124. http : **41;133688;TOOLONG </p> Madaus , J. , Bigaj , S. , Chafouleas , S. , &; Simonsen , B. ( 2006 ) . What key information can be included in a comprehensive summary of performance ? Career Development for Exceptional Individuals , 29 , 90-99. http : **41;133731;TOOLONG </p> Madaus , J. W , &; Shaw , S. F. ( 2007 ) . Transition assessment : Introduction to the special series . Assessment for Effective Intervention , 32 , 130-132. http : **41;133774;TOOLONG </p> Madaus , J. W. , Shaw , S. F , Miller , W. , Banerjee , M. , &; Vitello , S. ( 2011 ) . The Summary of performance : The reality and the possibility . Learning Disabilities : A Multidisciplinary Journal , 17 , 33-38 . </p> National Transition Assessment Summit . ( 2005 ) . Nationally ratified summary of performance model template . Retrieved from http : **62;133817;TOOLONG </p> Patton , J. R. , Clark , G. M. , &; @ @ @ @ @ @ @ @ @ @ performance system Computer software and manual . Austin , TX : PRO-ED . </p> Rehabilitation Act of 1973 , 29 U.S.C. 701 et seq . ( 2006 ) . </p> Shaw , S. F. ( 2009 ) . Transition to postsecondary education . Focus on Exceptional Children , 42(2) , 1-16 . </p> Shaw , S. F , Keenan , W. R. , Madaus , J. W , &; Banerjee , M. ( 2010 ) . Disability documentation , the Americans with Disabilities Act Amendments Act and the summary of performance : How are they linked ? Journal of Postsecondary Education and Disability , 22 , 142-150 . </p> Shaw , S. F , Madaus , J. W. , &; Dukes , L. L. , III ( Eds. ) . ( 2010 ) . Preparing students with disabilities for college success : A practical guide for transition planning . Baltimore , MD : Brookes . </p> Sopko , K. M. ( 2008 , March ) . Summary of performance : Brief policy analysis . Alexandria , VA : National Association of State Directors of Special Education . </p> Wehmeyer , M. @ @ @ @ @ @ @ @ @ @ Adult outcomes for students with cognitive disabilities three years after high school : The impact of self-determination . Education and Training in Developmental Disabilities , 38 , 133-144 . </p> TEACHING Exceptional Children , Vol. 44 , No. 5 , pp. 6-12 . </p> Stan F. Shaw ( Connecticut CEC ) , Senior Research Scholar and Associate Director , Center on Postsecondary Education and Disability , University of Connecticut , Storrs . Address correspondence concerning this article to Stan F. Shaw , Center on Postsecondary Education and Disability , Neag School of Education , University of Connecticut , Storrs , CT 06269 ( e-mail : stan.shaw@gmail.com ) . </p> Lyman L. Dukes III ( Florida CEC ) , Associate Dean , College of Education , University of South Florida , St. Petersburg . </p> Joseph W. Madaus ( Connecticut CEC ) , Director , Center on Postsecondary Education and Disability , University of Connecticut , Storrs . </p> 