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Black children with autism spectrum disorder (ASD) are diagnosed later than their White peers, are more likely to be misdiagnosed, and are less likely to receive early intervention services or a developmental evaluation by three years old. Using a grounded theory approach, we solicited the perspectives of parents and other primary caregivers of Black children with ASD on barriers and facilitators to ASD screening and referrals in primary care. A socioeconomically diverse sample of 22 female caregivers participated. Four themes emerged. First, while some caregivers noted their child's primary healthcare providers facilitated a timely ASD diagnosis, other participants reported these providers ignored early concerns about child developmental delays. Second, many participants felt racial bias negatively impacted caregiver-primary healthcare provider interactions. Third, legal/custodial issues slowed caregivers' abilities to follow up on referrals from their primary healthcare providers. Finally, caregivers described denial, shame, and stigma relating to ASD in the Black community as possible factors for delayed follow up to referrals. Differences based on socioeconomic status are discussed. Efforts to improve family-centered, culturally relevant care for all Black caregivers raising children with or at-risk for ASD are needed, particularly for those families experiencing the multiple effects of poverty.
Autism spectrum disorder (ASD) is a complex neurodevelopmental disability (American Psychiatric Association, 2013) affecting an estimated 1 in 59 children in the United States (Baio et al., 2018). Without known biomarkers, diagnosis relies entirely on professional observation and parent report of child behaviors (American Psychiatric Association, 2013). Primary healthcare providers, including pediatricians, nurse practitioners, and other medical professionals, play a critical role in facilitating timely ASD diagnoses and access to early intervention (Pinto-Martin et al., 2008). Once these providers identify a potential developmental delay, through parent report, clinical observation, or a standardized screening tool, the providers should refer children to specialists for a comprehensive developmental evaluation. Examples of specialists include early intervention professionals, psychologists with ASD training, and developmental pediatricians. Specialty services can vary from focused ASD programs to general early intervention services for children with developmental delays.
ASD can be reliably diagnosed by two years of age (Stone et al., 1999), and screening measures can identify children at risk for ASD by 12 months of age (Turner-Brown, Baranek, Reznick, Watson, & Crais, 2013). Timely diagnoses allow children to reap significant benefits from early intervention services (Christensen et al., 2016; Zuckerman, Lindly, & Sinche, 2015). Yet, while parents often bring their children's delays to primary healthcare providers' attention before the age of two (Chawarska et al., 2007); on average U.S. children are not diagnosed until they are over the age of four (Baio, et al., 2018).
National initiatives, such as the American Academy of Pediatrics' Autism A.L.A.R.M. (Johnson, Myers, & American Academy of Pediatrics Council on Children with Disabilities, 2007) and the Centers for Disease Control and Prevention's (CDC) “Learn the Signs. Act Early” campaign (Daniel, Prue, Taylor, Thomas & Scales, 2009) have attempted to raise awareness of the importance of early detection and intervention. For example, primary healthcare providers are encouraged to listen to caregivers' concerns and to refer children with suspected developmental delays to early intervention services or the local school system, even if not yet diagnosed. Part C early intervention services for children younger than three years old are available in every U.S. state through the Individuals with Disabilities Education Act. These services include a comprehensive developmental evaluation. Children not yet diagnosed with ASD or other developmental disabilities are eligible for Part C services, as long as they meet criteria for a developmental delay.
The CDC recently reported the prevalence of ASD among Black and African-American1 children continues to be lower than the ASD prevalence among White children, although the gap has narrowed compared to previous years (Baio et al., 2018). Black and White parents raise developmental concerns with their healthcare providers when their children are at similar ages (Jang, Matson, Cervantes, & Konst, 2014). Yet, compared to White children, Black children are diagnosed at later ages (Mandell, Listerud, Levy, & Pinto-Martin, 2002; Mandell et al., 2009), are more likely to be misdiagnosed (Mandell, Ittenbach, Levy, & Pinto-Martin, 2007), and are less likely to receive a developmental evaluation before age three (Christensen et al., 2016). In addition, the number of visits for Black children to receive an ASD diagnosis is on average three times more than for White children, with a longer period between initial provider contact and diagnosis (Mandell et al., 2002). Further, Black children are more likely to be diagnosed with more severe forms of ASD, suggesting underdiagnosis of children with milder forms (Jarquin, Wiggins, Schieve, & Van Naarden-Braun, 2011). Accordingly, studies have found Black children eligible for public (Part C) early intervention services were five times less likely to receive such services, compared to White children (Feinberg, Silverstein, Donahue, & Bliss, 2011); and, were underrepresented in ASD early intervention research (Dababnah & Parish, 2015).
A recent study offered an alternate perspective on past findings regarding ASD diagnostic disparities (Emerson, Morrell, & Neece, 2016). This research found that while Black children were diagnosed earlier than White children, having a consistent source of healthcare was associated with a later diagnosis for Black children, and an earlier diagnosis for White children. These findings suggest, despite potential improvements in primary healthcare screening and referral practices and having a consistent source of care, healthcare providers may not screen Black children for ASD and/or refer them to developmental specialists at the same rate as other children. Emerson and colleagues (2016) also discussed potential racial differences in parents and other primary caregivers following up on their healthcare providers' referrals to ASD specialists, which may be due to socioeconomic barriers or cultural beliefs.
Several studies have documented that, even when controlling for socioeconomic status, racial disparities in ASD diagnoses and services persist (Feinberg et al., 2011; Jarquin et al., 2011; Mandell et al., 2007). Nonetheless, few studies have investigated possible causes for these disparities. Recently, public health researchers have noted that existing theoretical frameworks were not designed to effectively investigate how structural racism may contribute to health disparities (Ford & Airhihenbuwa, 2010). Thus, Ford and Airhihenbuwa (2010) developed the Public Health Critical Race Framework (PHCRF), which incorporates a traditional behavioral model of healthcare utilization (Andersen, 1995), with both socioecological concepts (McLeroy, Bibeau, Steckler, & Glanz, 1988) and critical race theory (Valdes, Culp, & Harris, 2002). Andersen's (1995) healthcare utilization model is situated within an external environment, which includes the healthcare system and other environmental characteristics. The healthcare utilization model posits predisposing factors (e.g., race, age), enabling factors (which include individual, provider, and community characteristics), and need (both actual and perceived) all influence one's use of healthcare services, and ultimately, health outcomes (Andersen, 1995). The PHCRF challenges “race” as a factor that simply predisposes individuals to particularly health outcomes (Ford & Airhihenbuwa, 2010). Rather, it reframes the race-related predisposing factor as racism, which, along with structural racism in the external environment, create inequitable health outcomes for people of color.
While the PHCRF was originally applied to research exploring barriers to HIV testing among Black Americans, this model can potentially be adapted to understand ASD diagnostic disparities among Black children (see Figure 1). Enabling factors include community-specific cultural factors that can influence timely ASD diagnosis and treatment, including stigmatization of disabilities and increased reliance on kinship support (Burkett, Morris, Manning-Courtney, Anthony, & Shambley-Ebron, 2015). The PHCRF also considers income as an enabling factor. The poverty rate for Black Americans is the highest of all racial groups (22% in 2016; Semega, Fontenot, & Kollar, 2017) and poverty is an established risk factor for a missed ASD diagnosis (Daniels & Mandell, 2014). Potential healthcare provider-related enabling factors contributing to ASD racial disparities include inadequate professional training and provider bias (Gibson, 2007; Mandell et al., 2002); distrust of clinical care (Burkett et al., 2015); and, strained partnerships between primary care healthcare providers and Black families raising children with ASD (Magaña, Parish, & Son, 2015; Montes & Halterman, 2011; Pearson & Meadan, 2018; Zuckerman et al., 2015).
In total, the emerging research on racial disparities in ASD diagnosis has suggested there are several types of barriers to timely diagnoses and early intervention, including provider-related factors (e.g., insufficient training); stigma or other cultural issues; and, socioeconomic reasons. Healthcare provider-related enabling factors are considered to be more malleable to change, compared to environmental factors (Andersen, 1995), and can thus be potential targets for interventions aimed at reducing ASD diagnostic disparities. Such interventions must be informed by a better understanding of the enabling factors impacting ASD screening and referral practices. Primary healthcare providers are on the frontlines in screening and referring children in need of ASD diagnostic evaluations (Pinto-Martin et al., 2008), and patient-provider communication is central to the delivery of high-quality healthcare (Stewart, 1995). Thus, the current study explored the following questions:
What barriers and facilitators do parents and other caregivers of Black children experience regarding ASD screening in primary healthcare settings and subsequent referral to specialty care, such as comprehensive developmental evaluations?
Are there socioeconomic differences in primary caregiver-reported experiences?
We utilized a grounded theory approach to investigate primary caregivers' perspectives of ASD screening and referral practices in primary healthcare settings. Qualitative methods are particularly appropriate when the extant research base is weak and not inclusive of key stakeholders' perspectives (Sofaer, 1999). We conducted semi-structured individual interviews, which allowed us to ask participants a set of questions based on the past literature, while offering flexibility to participants to provide information not contained in the questions. The University of Maryland Baltimore Institutional Review Board reviewed the research protocol. All participants received information on their rights as human subjects before consenting to join the study.
This research was conducted in Baltimore, Maryland, where the majority population is Black/African-American (U.S. Census Bureau, 2015). The city is highly segregated along racial lines (Logan & Stults, 2011). Baltimore's poverty rate is 24.2% (U.S. Census Bureau, 2014). Approximately 60% of Baltimore residents live in areas where at least 20% of the population is below the federal poverty line (Maryland Department of Legislative Services, 2016).
We distributed recruitment flyers in English through clinics, community-based organizations, family support groups, and social media. Participants were eligible to participate in the study if they were (a) a primary caregiver (e.g., mother, father, grandparent, aunt) of a child 18 years or younger with ASD; (b) a Baltimore City/County resident; and, (c) self-identified as Black or indicated their child was Black. We did not independently verify child ASD diagnoses, as parent report is generally accurate (Daniels et al., 2012). We also did not restrict our study to young children, as research has found no evidence caregivers are inaccurate in their recall of first developmental concerns (Hus, Taylor, & Lord, 2011). Participants received $25 and light refreshments in appreciation of their time.
We interviewed 22 female caregivers, although the study was not restricted to women (see Table 1). While caregivers of any race were eligible to participate if they identified their child was Black, nearly all of the caregivers identified themselves as Black (n = 20; 91%). Income was evenly distributed in our sample. Over a quarter of participants (27%) reported household incomes less than $25,000 per year, and an additional 18% had incomes less than $50,000 annually. Approximately one-third of the participants reported household incomes over $50,000 and less than $100,000, while 23% reported incomes over $100,000 annually. Similarly, nearly half of the participants (46%) reported education completion at or before high school graduation, while 50% had college or post-graduate degrees. Six caregivers (27%) described professional experiences with ASD outside of caring for their children, including roles in special education and childcare.
Three (14%) participants were raising multiple children with ASD; thus, caregivers discussed their experiences concerning 25 children. All of the children were Black. The majority of caregivers reported their children had limited verbal language skills (n = 20; 80%). On average, caregivers reported concerns about their child's developmental progress around two years of age. About one-third (n = 9) of the 25 children received a diagnosis prior to three years of age. Child age at diagnosis averaged around four years, and ranged up to nine years old. Nevertheless, over half of caregivers reported that their child with ASD received early intervention services (n = 15, 60%); primarily through local Part C services (n = 14, 56%). Additionally, many stated that their child received services prior to confirming a diagnosis (n = 13, 52%).
Data Collection Procedures
The second author, a social worker with doctoral-level training in qualitative methods, conducted and audio-recorded the individual interviews at locations convenient to participants (e.g., caregiver's home), and maintained field notes from each interview. At the beginning of each meeting, the second author disclosed she is a Black caregiver of a child with ASD and indicated her willingness to discuss her own experiences following the interview. Before the interview began, each participant completed a background questionnaire, with information including the child's diagnosis, age of first developmental concern, and family structure.
The interview guide was comprised of ten questions and probes related to the research questions and relevant literature described in the introduction, and is available upon request from the first author. We split the guide into three sections exploring caregivers' experiences (a) obtaining the ASD diagnosis, (b) acquiring ASD services, and, (c) utilizing ASD services and collaborating with ASD service providers. The current paper focuses on results from the first section of our interview guide, which elicited participants' perspectives on their interactions with primary healthcare providers prior to obtaining a formal ASD diagnosis. We did not conduct cognitive interviews of, or otherwise formally pilot, our interview guide. However, consistent with the grounded theory approach (see Data Analysis section for more information), we conducted data analyses concurrently with data collection. This method allowed us to revise the interview guide to reflect emerging themes and add probes if necessary. We added two probes to the interview guide as a result of this process. Despite our discussion with participants during the consent process that our primary interest was the experiences of Black and African-American families, we recognized after the first three interviews that caregivers did not always directly discuss issues regarding race during the interview. Thus, we added a probe to explicitly ask participants about this question of interest to our study. Second, a theme began to emerge regarding participants' decision to join the research study. Thus, we added a probe to ensure we questioned future respondents on this issue.
Interviews, which were all conducted in English, averaged an hour in length. After completing each interview, the second author provided participants with an information sheet listing contact information for local ASD treatment and support services. If participants desired, the second author provided more details about these local services, as well as some information about her own experiences raising a child with ASD. The first author, an Arab American social worker with doctoral-level training, met with the second author following each interview to debrief interviews and preliminary analyses. During these meetings, we reflected on our positionality with respect to the interview participants, and how our past experiences could influence our understanding of emerging themes. For example, we had higher income and education levels than some of the participants. Particularly in these cases, we spent time exploring how our interactions with the participants might have been different had we been from the same socioeconomic group. We also reflected on the potential impact of the second author disclosing her own child's ASD diagnosis, and how that might have influenced participants' willingness to share their own experiences.
We used descriptive statistics in SPSS (IBM Corp, 2017) to summarize the background questionnaire. After the audio-recorded interviews were professionally transcribed, we analyzed interview transcriptions and field notes using grounded theory, a systematic process generating themes to understand a particular phenomenon (Strauss & Corbin, 1990). To further ensure quality, the third author, a White master's level social worker, reviewed interview transcripts for accuracy against the audio-recordings, before importing transcripts into NVivo11 (QSR International, 2015).
The first and third authors began the analysis by independently open coding words and short phrases in the transcripts and field notes, using NVivo11 (QSR International, 2015). Open coding is an established analytic method used in studies guided by grounded theory methodology, whereby responses are compared across participants and conceptual labels are defined in an iterative process (Corbin & Strauss, 1990). We used open codes and the interview guide to develop a preliminary codebook, which was refined as we inspected the data multiple times. Each coder maintained memos to log decisions throughout the analytic process.
Next, we critically examined the codebook to categorize codes into subcategories (axial coding). Throughout this process, we aimed to identify common themes shared by participants and participant responses that did not fit these themes (i.e., discomfirmatory responses). We used demographic information to investigate whether certain themes differed between subgroups. In particular, we explored differences in themes across socioeconomic strata (educational background and household income), to address our second research question.
As noted in the Data Collection Procedures section, we used analyses from completed interviews to inform future interviews. Further, our concurrent data collection and analyses allowed us to monitor when we had reached theoretical saturation. While Creswell (1998) recommended 20–30 participants for a study using grounded theory, there is little evidence for a set number of interviews needed to reach saturation (Guest, Bunce, & Johnson, 2006). Thus, we determined we had reached saturation when we not only began to understand some of the complexity within the themes themselves, but also how these themes connected to one another.
The first and third authors completed all data analyses. As noted above, both of these authors are social workers, and identify as Arab American and White American, respectively. We used several methods to improve the trustworthiness of our findings. First, in addition to the post-interview meetings between the first and second authors, the first and third authors met regularly with the second author to discuss emerging themes and all authors' positionality with respect to data collection and analyses. Second, we reviewed preliminary themes with a peer who was not part of the research team. This peer identified as Black and had experience in developmental disability policy and practice. Third, we actively sought responses that did not fit emerging themes (negative case analysis). Fourth, we compared our findings with past research to examine areas of overlap and divergence. Lastly, we maintained memos of our decision-making to create an audit trail of our analyses.
Our themes are situated within the PHCRF, shown in Figure 1. Additionally, we have listed selected characteristics of each participant in Table 2. With the exception of three caregivers (two who directly contacted early intervention services when concerned; one who did not have custody of her child pre-diagnosis), all participants described their experiences interacting with primary healthcare providers when their children first showed signs of developmental delays. The two caregivers who sought early intervention services directly, without their primary healthcare providers' involvement, were both professionals in early childhood and special education.
To address our first research question, we identified four broad themes describing caregiver-reported barriers and facilitators to ASD screening and referral practices in primary healthcare settings (see Table 3). To address the second research question, we detailed our findings regarding socioeconomic (household income and/or educational background) or other differences within each of the themes described below.
Theme 1: Primary Healthcare Providers' Attention to Caregiver Concerns
Primary healthcare providers' responses to caregiver concerns about developmental delays emerged as both a barrier and a facilitator to ASD screening in primary care and referral to further developmental evaluations. Although the majority of caregivers reported their child had received early intervention services, this occurred through two separate pathways. In the first pathway, participants reported their primary healthcare providers listened to their concerns and paid close attention to their needs. These providers referred families to early intervention services for developmental evaluations when either the caregiver or provider was first concerned. For example, one mother with a college degree (P11) noted her child was meeting milestones, but the mother felt “just little things were different about [child].” The mother reported her pediatrician told her, “Get out of here. Get out of here! Take [child] to [local specialty ASD clinic].” All of the children whose caregivers reported their primary healthcare providers listened to their concerns were diagnosed with ASD by four years old or younger, and many before three years old. One participant (P5), a mother with a high school education, discussed how, despite hearing concerns from daycare teachers, she was reluctant to follow-up until her child's pediatric office referred her to early intervention services, saying, “I was uncomfortable still, but it made me feel better that it was his nurse practitioner that said it's time to do something about this.”
The remaining caregivers reported that their primary healthcare providers did not seem to take their initial concerns seriously and did not provide immediate referrals for ASD screening services. One caregiver had concerns beginning when her child was three years old; the remainder expressed concerns from as early as a few months of age, to 2.5 years old. These participants described a second pathway to obtaining help for their children, which involved directly seeking early intervention services or persistence in asking for referrals from what P18, a mother with a high school degree, regarded as “nonchalant” primary healthcare providers. In a few instances, participants felt their providers did not offer a referral for an ASD evaluation because their child was a twin and/or premature, and thus developmental delays were expected. For example, one mother with a high school degree (P24), had concerns about her child's development by six months of age. She said by two years of age, “[Child] was already lining up toys or whatever, and I expressed that there and the doctor just kept saying, ‘No, he's too young. He doesn't show signs of autism.'” This mother, partly due to her child's other healthcare needs, did not question her primary healthcare provider's assessment regarding ASD. Her child was not diagnosed until about seven years old.
For others, the rationale for their primary healthcare providers' reluctance to provide a referral was unclear, which generally made their interactions with these providers frustrating. One mother (P1), a college graduate, described when her son's speech regressed between her 12- and 18-month well-baby check-ups:
I remember telling [pediatrician] that [child] is not saying any words. The pediatrician said, “Well, some kids, it takes some time. Some kids, might be until two to speak.” …[T]here was a point where [child] just stopped [speaking]. The foods he liked, he wasn't eating anymore…. I kept going to the pediatrician. “Something's not right. Why is he not speaking?” and [pediatrician] kept coming up with all these excuses…We gave it a few months, still nothing. I was like, “I'm very, very concerned.” I didn't know what was going on at all. But, all I knew was he's not talking and children are supposed to be meeting these milestones and he's not. We had to keep pushing.
In this case, the child was eventually diagnosed at age three after the mother persisted in identifying help for her child and contacted early intervention services directly. A few other caregivers, several of whom had prior professional experience in special education or ASD-specific services, described similar situations in which they directly sought early intervention or school-based services without their provider's referral. However, for nearly all of the caregivers who reported their providers were resistant to listening to their concerns, their children were diagnosed with ASD between the ages of four to eight years old.
When we looked at potential socioeconomic differences between caregivers who did and did not receive initial referrals from their primary healthcare providers, there was no discernible pattern of differences. In fact, we found that caregivers who reported their providers dismissed their concerns came from all income and education levels. However, there were observable differences within the subgroup who persisted in obtaining early intervention services, despite their initial experiences with their primary healthcare providers. Overwhelmingly, these caregivers had college or advanced degrees; or, household incomes greater than $100,000.
Theme 2: Perceived Racism and Poor Caregiver-Provider Interactions
The majority of caregivers reported unease in their interactions with their child's primary healthcare providers, which some perceived as racism. Other participants were unsure if poor caregiver-provider interactions were related to participants' neighborhood or socioeconomic status. One mother (P17) with a high school degree reflected on an interaction she had with a White parent whose provider had referred the White parent to an early intervention service: “My wheels are turning, and….initially my thought was, ‘Okay, she's White, I'm Black, maybe that's the reason I didn't get [the referral]. Then I said, ‘No, I don't think that's it. She doesn't have the same provider I have, she is still in [a different area of Baltimore].'” Other caregivers referred to racially segregated, low-income areas of Baltimore, with significant stressors such as violence and substandard housing, as potentially playing a role in how their primary healthcare providers perceived these caregivers and their families.
On the other hand, several caregivers discussed specific instances when they perceived racism led to their primary healthcare providers to make negative assumptions about them or their families. Participants reported these assumptions disrupted the caregiver-provider partnership, creating a barrier to ASD screening. For example, one mother (P16), a college graduate, described interactions with her primary healthcare provider, where she felt the provider doubted her knowledge about ASD and made assumptions about her income and family structure:
You assume because I'm Black… that I might not be as smart. So, I surprise you when I give you all the information. Maybe I was taking it the wrong way….I would get this whole lip service with the doctor, “Well, you can't do this with Medicaid.” I said, “I don't even have Medicaid, I have private insurance.”…There are assumptions like…I'm just this person that has multiple kids. This is a Black woman. If you see my three kids, you assume I don't have a husband.
Another mother (P25), who had a graduate degree, had a similar reaction from her primary healthcare providers when she came “knowledge heavy” [demonstrated a high level of knowledge], saying “I feel like I've shut it down because I'm not who [the providers] think I am.” However, she noted, “But I have had [Black] friends that have not had the same experience, and have felt that discrimination…That's very unfortunate, but I'm hoping to just be a part of that change.” Additional suggestions for change related to providers' perceptions of caregivers were echoed by another mother (P3), who also had a graduate degree. She particularly emphasized the importance of healthcare providers not overloading caregivers with information, saying:
[W]hen [providers] come into your space, or you come into theirs, just knowing that because I may not look the same as you, I may even on a bad day I may look like I don't have it all together, but don't make the assumption….Also everybody's different on the amount of information they're ready to receive, so just know that if you find out other ways to provide the information. Maybe it may not be giving it all to me right there, maybe say, “Can I get your email address?” or, “I can mail it out to you?” Sometimes an abundance of information is not good at one time for everybody, because everybody's at a different spot.
When looking at socioeconomic differences, we did not find any trends in participants who reported racism possibly influenced their interactions with their child's primary healthcare provider. However, among those caregivers who connected specific examples of providers' incorrect assumptions with their race, nearly all were highly educated and/or had high incomes.
Theme 3: Stigma in the Black Community
Many caregivers identified ASD stigma within the Black community, which made caregivers reluctant to follow up on, or even acknowledge, early developmental delays expressed by their primary healthcare providers or others. Several participants asserted that denial or shame related to having a child with special needs is prevalent in the Black community, which reduced awareness of ASD. Some caregivers mentioned they only found out children of family members or friends had special needs after the caregiver's own child was diagnosed with ASD. One mother (P16) with a college education said:
…Other Black parents that have kids with special needs, I think there are a lot in denial…I think mental illness is something you just don't talk about. Technically autism isn't a mental illness, it's a developmental disorder, but you kind of just keep them on the side. A lot of people come up to me like, “I knew nothing about autism.” I have a cousin that's autistic, but they don't really talk about him because they leave him in the house. I normally take [child] out with me.…People see there is a child that has autism, but he doesn't have to be acting erratic.
Another mother (P26) with a graduate degree asserted denial and the fear of “labeling” a child with special needs might delay some parents from seeking assistance when healthcare providers or others expressed concerns about their child's development. Nonetheless, this mother described how she ignored others' denials of her concerns, saying:
We [the Black community] don't follow our gut sometimes. We listen. My mother apologized to me. [She had said], “Oh, they're preemies, they're twins, they're boys.” [I said], “Mm-hmm [affirmative]. I hear you,” as we're going to [local clinic]. We have a hard time with the label.…You see him toe-walking and no eye contact and, “Oh, he just needs a little bit of speech.” No. He needs a little bit more than that.
Like this caregiver, other participants noted their family members, most commonly the children's fathers, were resistant to the “autism” label. One mother (P5) with a high school education said, “[Child's] father actually just told me, a month or so ago, that he's not fully comfortable with [child's diagnosis]. He doesn't really know what it is. He doesn't want anyone to judge his son.” Others mentioned grandmothers or older family members insisted prayer or discipline, rather than seeking a developmental evaluation, would address children's challenging behaviors.
On the other hand, several caregivers recalled times in which their family or friends pushed the caregivers to attend to concerns about ASD, despite the stigma. In particular, these participants noted older family members and trusted friends shared information on ASD and typical child development to encourage caregivers to seek developmental evaluations for their children. Caregivers used this information to share concerns with their child's primary healthcare provider, or to directly seek early intervention services.
We did not identify any themes based on ASD-related stigma within certain socioeconomic categories. Rather, participants across income and educational levels reported stigma as a barrier to Black families attending to concerns about delayed child development; and, described family members and friends both as potential barriers and facilitators to overcoming stigma in order to follow up on developmental concerns.
Theme 4: Legal and Custodial Issues
Changes and disruptions in caregiving and custodial arrangements created a barrier to following up on ASD screening and their primary healthcare providers' referrals to developmental evaluations for some caregivers, delaying their child's ASD diagnosis. Some caregivers were not their child's biological parent (e.g., grandparent), and discussed legal challenges that prevented them from making medical and treatment decisions on the child's behalf for developmental concerns. However, legal and custodial issues also arose for the biological mothers in our sample. For example, one participant (P10), a mother with no high school degree, expressed general distrust of providers due to negative experiences with the child welfare system. This lack of trust seemed to influence her willingness to follow up on her own and her child's primary healthcare provider's concerns about her child's development as early as two years old. Thus, she explained why her son was not diagnosed until nearly seven years old:
My [other] son passed away. [Child Protective Services] took [child later diagnosed with ASD] from me that night. He was gone for like seven months. Once I got him back, I didn't take him nowhere. I didn't want nobody in it. Once he started his new school and being around older kids, and still seeing a difference between him and the other kids, then that's when I wanted to get the diagnosis.
Another mother (P27), whose education was not reported, stated an informal caregiving arrangement due to her incarceration contributed to her son's delayed diagnosis. She noticed developmental delays around three years old, but then:
I got a little minor misdemeanor that sat me in jail [for two years]. The person that I left the guardianship to was the wrong person…[Child] was about six years old when I got out and got [children] together for school, missed all their shots….That's when [child] was diagnosed [with ASD].
Although legal or custodial issues were not exclusive to participants with low incomes and/or limited education, the majority of caregivers who noted these types of issues reported household incomes of $25,000 or less, and high school education or below. While not directly related to their primary healthcare providers, some participants who endorsed this theme acknowledged poverty-related stressors (e.g., substandard housing) exacerbated their legal or custodial challenges, and further contributed to delays in following up on child developmental concerns.
Our research collected the perspectives of a socioeconomically diverse, urban sample of parents and other primary caregivers of Black children with ASD. We have situated our findings within the Public Health Critical Race Framework (Figure 1). Within this framework, we identified several barriers and facilitators related to provider, community, and individual enabling factors, which ultimately influence ASD screening, referral to specialty services, and caregiver follow up (Table 3). While our focus was on enabling factors, we note these processes occur within a larger environmental context. In the current study, caregivers resided in an urban area with high levels of racial segregation and concentrated poverty. While environmental characteristics are not as malleable as provider-related enabling factors (Andersen, 1995), they are nonetheless important to recognize as potential drivers to the racial disparities in ASD diagnoses.
Healthcare providers' attention to caregiver concerns has already been recognized as a critical facilitator to timely ASD diagnoses, with ongoing national efforts to raise providers' awareness of the accuracy of caregivers' early developmental concerns (Johnson et al., 2007). Our study findings suggest some progress has been made to take caregivers' early developmental concerns seriously, with some participants reporting their primary healthcare providers referred children to early intervention services when developmental delays were first identified. Furthermore, over half of the caregivers reported accessing early intervention services before their child was diagnosed with ASD, primarily through Part C programs. It is possible there is growing awareness that public early intervention services are available for young children with developmental delays. Clearly, more research is needed to explore these potential trends in larger samples.
Despite this progress, many caregivers in our study, across socioeconomic strata, reported delays in the referral process due to their primary healthcare providers' inattention to caregivers' concerns. Pearson and Meadan (2018) identified a similar finding in their study focusing on Black caregivers raising children with ASD. Providers' lack of response to caregivers' worries about their children's development is one potential contributor to the persistent screening and referral disparities for Black children at risk for ASD (Baio et al., 2018; Emerson et al., 2016). Further, some caregivers noted their primary healthcare providers attributed child developmental concerns to prematurity or low birthweight, conditions that disproportionately affect Black children (Giscombé & Lobel, 2005). Those parents who ignored their providers' advice to “watch and wait” and directly sought early intervention were mostly of higher socioeconomic status, which aligns with earlier research finding children in impoverished families or with limited education are especially vulnerable to missed or delayed diagnoses (Daniels & Mandell, 2014).
The second theme, related to perceived racism and poor caregiver-provider interactions, was also a clear provider-related barrier to appropriate screening and referral practices. Indeed, the majority of caregivers felt racism affected their experiences seeking primary healthcare services for their child with ASD, and expressed a need for more respectful, individualized communication with their child's provider. These findings add to the broader literature base that Black patients report lower levels of trust in the medical establishment, which may be ameliorated in part by building stronger parent-provider partnerships and improving access to healthcare services (Benkert, Peters, Clark, & Keves-Foster, 2006; Halbert, Armstrong, Gandy, Jr., & Shaker, 2006; Horn, Mitchell, Wang, Joseph, & Wissow, 2012). Yet, compared to White caregivers, research has found Black caregivers of children with ASD are less likely to report their provider spent enough time with the child, was sensitive to their family's values, and worked as a partner with the parent; all hallmarks of high-quality, family-centered care (Magaña et al., 2015; Montes & Halterman, 2011).
In addition to the two provider-related enabling factors, study participants emphasized that cultural stigma in the Black community related to ASD can contribute to caregiver resistance to seek developmental referrals from their primary healthcare providers, or to follow up on such referrals, supporting past research that cultural factors can impact timely diagnosis and treatment (Burkett et al., 2015; Pearson & Meadan, 2018). Participants across the socioeconomic spectrum identified stigma as a barrier. It is important that primary healthcare providers are aware of cultural influences, such as stigma, that may affect care (Burkett et al., 2015). Additionally, these providers have an opportunity to help ameliorate stigma by engaging in community initiatives that can improve ASD awareness and knowledge. Outreach and partnerships with Black communities could not only help reduce stigma, but it may also serve to increase trust between primary healthcare providers and caregivers, as well as with the wider community.
Our results also suggest that support from family members and friends can motivate caregivers to seek assistance for their children. Primary healthcare providers should routinely discuss and problem-solve issues related to partner and family support with caregivers, as well as include other family members and friends in healthcare conversations when appropriate. Indeed, directly providing support through therapeutic communication, as well as involving patients and their family and friends in shared decision-making are key components of patient-centered communication that healthcare providers should be incorporating into their practices (Street et al., 2009). Additionally, primary healthcare providers can connect caregivers to outside support and/or resources (e.g., ASD support groups), a method by which providers can indirectly improve social support (Street, 2013).
Lastly, our findings highlighted legal and custodial challenges as a barrier to caregivers attending to their primary healthcare providers' concerns and following up on their referrals. Families with these types of challenges might need additional time and support from their providers to seek assistance for child developmental delays. However, negative experiences with other formal systems, such as child welfare services, might exacerbate existing mistrust Black patients have in the healthcare system (Burkett & Morris, 2015; Gallagher, 2014). In order for primary healthcare providers to increase trust and encourage caregivers to share and follow up on concerns regarding developmental delays, it is critical to provide trainings and courses in medical schools that support the development of race consciousness. Providers who view their practice through a lens of race consciousness will be deeply aware of their own racial position and can be attentive to how racial stratification could impact interactions with patients of other races (Bell, 1991; Ford & Airhihenbuwa, 2010).
Our study was limited to data collected only from parents and other primary caregivers. Data collected from other sources, such as primary healthcare providers and/or medical records, would strengthen our understanding of potential barriers to ASD screening and referral processes in primary healthcare settings. Furthermore, this research is also limited by a sample consisting almost exclusively of urban mothers. This is an important distinction, as rural children face unique obstacles to obtaining an ASD diagnosis (Daniels & Mandell, 2014). Additionally, fathers and other caregivers report different perspectives than mothers on caring for a child with ASD (Hastings et al., 2005; Hillman, Wentzel, & Anderson, 2017). More research is needed to investigate the specific needs of caregivers representing the diversity of U.S. families.
Research and Practice Implications
While several large studies have demonstrated persistent racial disparities in ASD diagnoses, little work has been done to investigate the root of these differences, particularly from parents and other primary caregivers' perspectives. Therefore, this research aimed to uncover some of the complex barriers and facilitators to timely ASD diagnoses for Black children, at the crucial junction of screening and referral in primary care. Our interviews with caregivers of diverse socioeconomic levels enabled us to begin to disentangle the effects of race versus poverty on ASD screening and referrals. We found that across nearly every theme, caregivers reported barriers, regardless of their income or educational level. Additional studies are needed to understand how provider, individual and community enabling factors interact with one another, as well as how they operate within specific healthcare and geographic settings.
The four interrelated themes we identified in this study have direct implications for pediatric primary healthcare providers, as well as for larger efforts to reduce the troubling racial and socioeconomic disparities in timely ASD diagnoses. Training for primary healthcare providers that incorporates techniques such as values affirmation and awareness of implicit biases are particularly important for improving communication in race-discordant healthcare relationships (Havranek et al., 2012). Addressing this aspect of communication is key, as the perceived racism that caregivers experienced in our study has been echoed in other research with this population (Lovelace, Robertson, & Tamayo, 2018). Furthermore, including paraprofessionals and community health workers to facilitate communication between parents and providers can reduce unmet health needs (Guerrero, Inkelas, Whaley, & Kuo, 2013). As a significant proportion of caregivers reported accessing early intervention services, there are potentially opportunities for collaboration between primary healthcare providers, early intervention professionals, and children's caregivers to address child developmental concerns early. The development of collaborative partnerships has also been identified by Black caregivers of children with ASD as an important facilitator in gaining access to ASD services (Pearson & Meadan, 2018). Finally, additional barriers to timely diagnoses impacted some of the more vulnerable families in our study, including those with limited education or income, as well as those with children with preexisting developmental challenges. Thus, continued efforts to disseminate Autism A.L.A.R.M. guidelines to primary healthcare and other frontline providers will ensure more families receive access to appropriate ASD interventions. Clearly, federal, state, and local public policies to support efforts to reduce poverty and address structural racism will increase the impact of the work at the primary healthcare level.
The literature about the unique issues affecting Black families raising children with ASD is only just emerging. Interventions to train primary healthcare providers to become conversant on matters affecting Black families, especially in cases in which those families are experiencing the multiple effects of poverty, are crucial to reducing racial disparities in ASD screening, and ultimately, diagnosis and intervention. As the main gatekeepers to specialty developmental and ASD-specific services, primary healthcare providers play a critically important role in delivering culturally relevant care and ensuring all children have an equal opportunity to obtain timely ASD diagnoses and access early interventions.
We recognize individuals in the African diaspora within the U.S. (and elsewhere) have different preferences with respect to using “Black,” “African-American,” or other terms to self-identify (Cross, 1991). However, in an effort to be inclusive, we use the term “Black” in this article to refer to any individuals of African descent.
We appreciate the funding support of a Competitive Innovative Research Award, University of Maryland Baltimore. In addition, we are very grateful to the caregivers who participated in this research and shared their experiences with us. More than 25 organizations supported this study by agreeing to recruit families. We would like to thank them all, particularly The Arc Baltimore, The Center for Autism and Related Disorders, Family Connections, the Interactive Autism Network, and PACT (Kennedy Krieger Institute). Finally, we recognize Dr. Nalini Negi for reviewing an earlier version of this manuscript.


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Dance Classes For 2 Year Olds Milton Keynes. (currently suspended due to covid) i’m adding to this directory all the time. 768 likes · 8 talking about this · 100 were here.
Ad learn dance online at your own pace. Ad learn dance online at your own pace.
Le Corsaire ENB Ballet Positions Ballet Performances
Adults can enjoy classes in ballroom and latin, rock ‘n’ roll, line dancing. All classes take place on a saturday during milton keynes term time at the newton leys pavilion, newton leys, milton keynes.
For 2 Year Olds Milton Keynes
Attitude school of dance, milton keynes.Cfda dance lessons are enjoyed by over 350 dance students across milton keynes and newport pagnell my two daughters have been dancing at coles forsyth dance acadmey since they were 3 and 4 years old.Classes are taught by experienced and professional teachers, teaching a variety of styles, including:Classes run weekly in milton keynes.
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When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies.Who i took to music bugs classes from when she was a baby following a.£2 per family per week.

domain: hobby


Latest Of June Stories
LOS ANGELES, Nov. 3 /PRNewswire/ -- Universal Music Publishing Group (UMPG) today announced the signing of an exclusive world-wide publishing agreement with No. 1 songwriter/artist Adam Young of Owl City. The publishing deal encompasses all of the Owl City catalogue, including Adam's major label debut Ocean Eyes. "We couldn't be happier to be working with David Renzer, Tom Sturges, Evan Lamberg and the entire UMPG team," said Steve Bursky, management of Owl City. "Their creativity and...
- Like a worm in form or movement; vermiform; tortuous or sinuous; also, writhing or wriggling.
- Like the track or trace of a worm; appearing as if worm-eaten; vermiculate.
- Marked with fine, close-set, wavy or tortuous lines of color; vermiculated.
- A form of rusticated masonry which is so wrought as to appear thickly indented with worm-tracks.


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Author(s) Filipa do Carmo Almeida Santos Silva
Advisor(s) Joaquim Freitas Rocha
Synopsis With the present study it is intended to analyse the excessive deficit procedure in the context of the Economic and Monetary Union (EMU), considering its importance and role as an instrument for economic policies coordination in the European Union (EU) and its role in the framework of the Stability and Growth Pact (SGP). Our purpose is to address it from a legal perspective, focusing our attention on the adequacy rules parameter that densifies your existence and your frame of reference. The analysis starts by outlining the essential dimensions of the positive legal framework and the “state of the art” of the current coordination of financial policies under the EU’s economic governance agenda. It is intended to set the context of the adoption of the SGP, and therefore the excessive deficit procedure, in the process of economic integration set up by the creation of the EMU, which find its base in the sound and stable public finances principles. The focus will be on the major step the EMU represents in the integration of EU economies and the significant evolution of the SGP along with the EU’s economic governance rules. Taking into account that for the effective implementation of these principles the EU adopted several control mechanisms targeted at introducing austerity and discipline in national public budgets, the second part aims to, at first, analyse the SGP as a set of legal and financial rules designed to ensure that Member-States in the EU pursue budgetary discipline and, afterwards, its successive amendments in an effort to allow it to better fit with economic governance rules. In the third part of our study, we study the excessive deficit procedure following an in-depth understanding of its legal and conceptual content in relation to the EU law. Our approach seeks to identify its compatibilities and flaws whilst outlines possible solutions that have been continuously found since the SGP entered into force. Particular attention was paid to the judgment of the Court of 13 July 2004, Commission of the European Communities, v. Council of the European Union, (Case C – 27/ 04).
See more here.

domain: politics


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NEW YORK (MarketWatch) — After trading above $1.10 for most of the North American session Monday, the euro abruptly fell in midafternoon trade, but remained higher on the day.
The shared currency hit a session high of $1.1048 in morning trade, before it started drifting lower. At around 3:05 p.m. Eastern Time, the euro suddenly plummeted, shedding about 65 pips (a pip is the smallest unit of change in a currency pair) in 15 minutes.
Mike O’Rourke, chief market strategist at Jones Trading, said the sudden decline was likely triggered by selling resistance above the $1.10 level.
“[The euro] basically tried to push through $1.10 today. It did briefly this morning. It couldn’t sustain it, then you had some type of unwind,” O’Rourke said.
Boris Schlossberg, managing director of FX strategy at BK Asset Management, said that rising Treasury yields caused currency traders who were short the dollar to flip positions.
“We’ve had a big rally in 10-year yields, and the rally accelerated as the day went on. That created a very sharp dollar rally in the currency market,” Schlossberg said.
Earlier in the session, traders pushed the euro higher after New York Federal Reserve President William Dudley said that the strong dollar has given a “significant shock” to the U.S. economy, and after the Institute for Supply Management’s nonmanufacturing index showed slowing growth in the U.S. service sector.
Matt Weller, a senior technical analyst at Forex.com, said that the euro’s gains are a sign the market has pushed back its expectations for when the Federal Reserve will begin raising interest rates.
“After shedding over 3,500 pips in less than a year, the world’s most widely-traded currency pair is seeing its largest rally since topping above 1.40,” Weller said in a note to clients.
The ICE U.S. Dollar Index
Trading activity in Asia and Europe was subdued, with many traders still away for the Easter vacation and other public holidays.
Friday’s tumble in the dollar was the biggest fall in almost two weeks following U.S. labor data for March that showed nonfarm payrolls grew by 126,000, about half the increase forecast by economists in a Wall Street Journal survey.
The WSJ Dollar Index

domain: news


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Mr Stephane Cael (Thales)
Presentation will be focused on CAN bus at the heart of the TAS avionics architecture and, in particularly, on: - Architecture of CAN bus in THALES ALENIA SPACE design. - Validation strategy of the CAN bus. - CAN validation results: *Electrical tests *Functional tests - Going further / free discussions: *Step forward with integration of the Applicable Document AD919 in ECSS. *Further FDIR management: Improve CAN failure monitoring (identification of the failed unit). Improve CAN failure auto isolation."

domain: design


California Department of Corrections and RehabilitationPelican Bay State Prison Inmate Arturo Castellanos
One man was a petty thief mistakenly identified as a player in a violent Latino prison gang. The other was a convicted murderer whose numerous assaults behind bars and continuing influence on the streets earned him a reputation as a ruthless gang leader.
The fact that both men were locked for years in grim, windowless isolation cells at Pelican Bay State Prison illustrates the challenge that corrections officials face as they overhaul the state’s controversial Security Housing Units.
Opened in 1989, Pelican Bay was designed to house California’s most dangerous inmates. The prison’s Security Housing Unit goes a step further, locking inmates identified as prison gang members or associates in a warren of concrete cells where the only view of the outside world is framed on small television sets. Some inmates have been housed in the units since Pelican Bay opened its gates.
Corrections officials say the lengthy confinement and extreme security measures are necessary to curb the ability of gang leaders to pass orders to subordinates in other prisons and on the streets. And they point to inmates like Arturo Castellanos to make their case.
Castellanos was convicted of murder in Los Angeles County in 1979 and sentenced to 26 years to life. But his life of crime flourished behind bars, according to prison records.
As an inmate, Castellanos’ disciplinary record includes six stabbings and various drug violations. In 1990, he was sent to Pelican Bay’s Security Housing Unit after corrections officials identified him as a member of the Mexican Mafia prison gang.
In spite of Pelican Bay’s harsh conditions, authorities allege Castellanos continued to command gang members on the street through edicts smuggled out of prison on tiny scraps of paper known as “kites.”
According to a 2007 federal indictment, Castellanos guided a Latino street gang known as F13 as it launched a turf battle against African American rivals. The action triggered a wave of racial violence against African Americans living in the Florence-Firestone area north of Watts, according to court documents. More than 20 people were killed.
“I was just amazed that an individual who no one has seen for generations was able to control the violence and illegal criminal activity of an area that he hasn’t been to in more than three decades,” said Peter Hernandez, an assistant U.S. attorney for California’s Central District.
Federal prosecutors eventually indicted 104 suspects in the case, but not Castellanos. He already was serving a life sentence, and the government concluded it was safer to keep Castellanos in isolation and not pull him out of Pelican Bay for court hearings, which would have been required had he been indicted.
“It was important that … Castellanos not be let out, because he holds sway over gang members to do things they would otherwise not want to do,” Hernandez said.
Since 2006, Castellanos has been housed in a special section of Pelican Bay’s Security Housing Unit that is reserved for inmates deemed influential gang leaders.
But that didn’t stop him and three other inmates from organizing a three-week hunger strike to demand better conditions and changes in department policy.
During a recent media tour, Pelican Bay acting Warden Greg Lewis claimed the four hunger strike leaders, including Castellanos, were in the upper echelons of major prison gangs and continued to pose a serious security threat. Lewis said the men are “intelligent, very manipulative and possess the intellect to orchestrate what they did.”
Michael Montgomery/California Watch Ernesto Lira near his home in Planada, Calif.
While prisoner rights advocates concede that some inmates should be segregated from the regular prison population if they are violent or directly involved in criminal conspiracies, they say the actual number of offenders who fit that criteria is very small.
“The California Department of Corrections and Rehabilitation always picks the worst-case scenario and uses it as the norm,” said Carol Strickman, a staff attorney at Legal Services for Prisoners with Children.
Not all the inmates locked in the Security Housing Unit are accused of being gang bosses.
Ernesto Lira was serving a sentence for drug possession in a low-security prison when he was sent to Pelican Bay for an “indeterminate” term. Authorities contended Lira was an associate of a violent Latino group known as Nuestra Raza.
Continue Reading @ California Watch


Release date: January 11, 2021
The Wisconsin Department of Transportation (WisDOT) today announced that communities across the state received $126 million in transportation funding payments on January 4, the first quarterly payments for 2021.
For calendar year 2020, local governments received more than $505 million in general transportation aids (GTA) financial assistance to support transportation related projects; a 10 percent increase over calendar year 2019 allocations.
“These payments represent part of the cooperative work we do with local governments across the state to keep goods and services moving throughout Wisconsin,” WisDOT Secretary-designee Craig Thompson said. “We are committed to investing wisely and working hard together to come up with innovative, efficient transportation solutions.”
The local assistance increase is part of more than $465 million in new funding for transportation projects included in the 2019-2020 state budget, the largest dedication of new, ongoing revenue to the transportation fund in a generation. In addition to the 10 percent GTA increase, the budget included $320 million in new funding for the State Highway Rehabilitation program and provided $90 million in one-time funding for the Local Roads Improvement Program-Supplement grant program.
The first quarter payments to Wisconsin’s 1,922 villages, towns, cities, and counties included:
- General Transportation Aids - $126,426,597.10 to all local governments
- Connecting Highway Aids - $3,015,874.20 to 116 eligible municipalities
- Supplemental Transportation Aids - $1,758,896.85 to 96 towns
- Expressway Policing Aids - $255,975.00 to Milwaukee County
General Transportation Aids help cover the costs of constructing, maintaining, and operating roads and streets under local jurisdiction. Connecting Highway Aids reimburse municipalities for maintenance and traffic control of certain state highways within municipalities.
Quarterly payments for cities, towns and villages are sent the first Monday in January, April, July and October. County payments are made in three installments, with 25 percent of the total annual payment on the first Monday in January; 50 percent on the first Monday in July; and 25 percent on the first Monday in October.
For more information, contact:
WisDOT Office of Public Affairs


The Cyber Space has become an important factor in the modern terrorism strategy. Not only are terrorists using the internet to advance their goals, they are also innovating and adapting to changes in the technological environment. In order to fight terrorism effectively, we must seek to understand how terrorists are adapting to new technological changes and in which ways they are using online networks to learn and spread technical information and knowledge. Although terrorists usually lack the resources of security agencies, they are often one step ahead of security agencies who are trying to monitor the jihadist use of the internet, to geo-locate jihadist internet users, and to monitor and disrupt jihadist online communication. The goal of this paper is to analyze jihadist cyber security and more concrete the content of Kybernetiq, the first jihadi magazine on cyber and information security.


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Pant Du is a family run Vineyard and Orchard, established in 2007 by Richard and Iola Huws. Pant Du produce includes Wine, Cider, Apple Juice, Spring Water and Honey. Over the years Pant Du have won many awards and accolades for their unique Welsh products.
9 acres of vines and 18 acres of apple trees have been planted on the former farmland, transforming the slopes of Dyffryn Nantlle valley.
Pant Du produce can be bought from the small on-site shop, and our Online Shop.
There are 6 different varieties of vines planted on the slopes of Pant Du - Seyval Blanc, Sigrrebe, Souvignon Blanc, Pinot Noir, Frühburgunder / Early Pinot Noir, Rondo. These special grape varieties were specifically chosen to work well with the soil and climate conditions here in North Wales. White, Red and Rose wines are produced.
White - Light fresh aromatic dry white wine, very light pale in colour with a hint of elderflower on the nose. On the palate green apple with a touch of citrus and very clean on the finish. Well balanced in its acidity.
Red - Very light and fruity with a strong nose of red berry fruits. Low in tannin. Easy drinkable with great summer fruit flavours on the palate to finish.
Rose - A full flavoured Rose with a vibrant summer fruit and strong wild strawberries on the nose. Nice and light. Good balanced in its acidity with a touch of sweetness to finish.
3,200 apple trees are planted at the Pant Du Orchard, 2,000 of them are traditional cider apple trees, and the rest are native Welsh apple trees.
Pant Du Cider is pressed from traditional cider apples and Welsh variety apples. The result is a pure craft cider, fresh and fruity, full of apply taste.
Pant Du produces five types of Cider - Dry and Medium Dry, as well as Rhubarb flavoured Cider, Wild Fruit Cider, and Passion Fruit & Lime Cider.
700 of the native Welsh varieties that are plated at Pant Du are Bardsey Apple trees, a variety that was at one time almost extinct. Through planting so many of the trees Pant Du are contributing towards the development and future of the historical apple from the Llyn Peninsula.
Pant Du produces 3 varieties of apple juice. The Still and Sparkling Apple Juice are made using a variety of apples; the Bardsey Apple Juice is made with a single apple variety.
The water is filtered naturally as it travels through the Pre-cambrian rocks that are over 500 million years old, as a result the water is exceptionally pure and natural.
The water is balanced in minerals; Low in sodium, and with a perfect pH of 7.35 - the ideal level for the body.
The first Honey pot was produced in 2017.
The bees work tirelessly through Spring flying between the flowers of the apple trees collecting nectar, to produce the honey.
This process by the bees transfers pollen from one apple tree to another, a process that is vital in the formation of apples, that will later be produced into Cider and Apple Juice.

domain: agronomy


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The world is becoming more interconnected and remote work is no longer a foreign concept. With the rise of digital nomads, people can now work from anywhere they choose. Digital nomads are individuals who use technology to perform their jobs from anywhere in the world. These location-independent workers have embraced the nomad lifestyle, which allows them to travel while working.
One of the most important decisions that digital nomads must make is choosing where to live and work. With so many destinations available, it can be difficult to decide on a location that meets all their needs. This article aims to explore this topic and answer the question, “Where is the best place for digital nomads?”
To better understand this question, let us define what digital nomads are. They are individuals who use technology to perform their jobs from anywhere in the world, allowing them to have a lot of freedom in terms of where they live and work.
The keyword “Where is the best place for digital nomads” raises an interesting point about how important location is for remote workers. It acknowledges that there are certain factors that make some places more attractive than others for telecommuting professionals.
In this article, we will explore popular digital nomad destinations as well as lesser-known locations that offer unique opportunities for remote workers. We will also discuss various factors such as cost of living, internet connectivity, community and networking opportunities, safety, and security that one should consider when choosing a destination.
Lastly, we will provide additional tips such as finding accommodation or managing finances while traveling that can help make life easier for those pursuing this type of lifestyle.
So sit back and get ready to learn about some exciting options available for those seeking a mobile workforce and global mobility!
Popular Digital Nomad Destinations
Bali is a digital nomad hotspot due to its idyllic island location, warm weather, low cost of living, and friendly local culture. Its affordability makes it a popular destination for remote workers who are budget conscious. Bali offers an extensive co-working scene with various shared spaces that cater to digital nomads.
Co-working spaces like Dojo Bali offer an inspiring environment for remote professionals who want to stay productive while enjoying the benefits of an island lifestyle. The space offers high-speed internet, ergonomic chairs, standing desks, and even a pool for when you need a break from work.
In addition to its co-working facilities, Bali has many activities that make it an attractive destination for digital nomads. You can go surfing in the morning before checking into your co-working space or attend yoga classes in the afternoon. There are also plenty of opportunities to explore Ubud’s rice terraces or enjoy Balinese massages at local spas.
Chiang Mai, Thailand: The Hub of Digital Nomads
Chiang Mai has been dubbed as one of the most affordable destinations for digital nomads in Asia. It is favored by many because it has all the amenities you would expect from a big city without the big city price tag.
The cost of living in Chiang Mai is significantly lower than most Western countries making it easy for remote workers on tight budgets. The city boasts numerous cafes and restaurants that offer excellent Wi-Fi speeds which makes it convenient for those who like working at coffee shops.
Due to its popularity with remote workers over the years, Chiang Mai has become a hub of digital nomad activity with several co-working spaces available throughout the city such as PunSpace and Maker Club. These co-working spaces provide ample opportunities for networking with others within the digital nomad community.
Lisbon, Portugal: A European Gem for Digital Nomads
Lisbon is a beautiful destination that offers an ideal mix of culture, history, and stunning architecture. With its cobbled streets, local cuisine, and vibrant nightlife, Lisbon has become a popular destination for remote workers who want to experience the best of Europe while maintaining their work-life balance.
The city has numerous co-working spaces with high-speed internet connections and excellent facilities like Cowork Central or Impact Hub Lisbon. There are also several cafes that offer free Wi-Fi within the city where you can work comfortably while enjoying Portuguese coffee.
For those looking to unwind after a long day’s work, Lisbon’s scenic beaches and parks offer the perfect escape for digital nomads to recharge their batteries. From surfing in Cascais to exploring Sintra’s palaces and castles, there’s plenty to discover in this culturally rich city.
Medellin, Colombia: South America’s Digital Nomad Capital
Medellin is one of the most vibrant destinations in South America that has quickly become a hub for digital nomads. It is known for its great weather, cultural experiences, and affordable cost of living making it an attractive destination for remote workers from all over the world.
There are many co-working spaces available throughout Medellin like Selina Cowork or Atomhouse where you can network with other professionals within the digital nomad community. For those who prefer working at cafes instead of co-working spaces, Medellin has plenty of options available such as Café Velvet or Pergamino Café.
In addition to its thriving co-working scene, Medellin offers numerous activities where you can immerse yourself in Colombian culture such as salsa dancing lessons or exploring the famous Comuna 13 street art district.
These popular destinations offer remote workers great value on the cost of living without compromising on quality lifestyle experiences like fine dining, outdoor activities, and cultural immersion.
Where Is The Best Place For Digital Nomads?
Lesser-Known Digital Nomad Locations
The Charm of the Caucasus
Tbilisi, Georgia is a lesser-known location for digital nomads, but it’s one that shouldn’t be overlooked. This Eastern European city has a rich history and culture, which makes it an interesting place to explore while living the nomad lifestyle. The cost of living in Tbilisi is low compared to other European cities, making it an affordable destination for those looking to save money while they work remotely.
For remote workers who value outdoor activities, Tbilisi offers plenty of opportunities to explore nature. Hiking trails in the nearby Caucasus Mountains provide stunning views and fresh air. The city itself has beautiful architecture and interesting museums that offer a glimpse into Georgian history and culture.
There is also a growing digital nomad community in Tbilisi with co-working spaces popping up all over the city. Many cafes have free Wi-Fi and are welcoming to people who bring their laptops to work from there. It’s easy to connect with other like-minded individuals in Tbilisi’s growing digital nomad scene.
Da Nang, Vietnam
Vietnam’s Hidden Gem
Da Nang is another destination that may not be on everyone’s radar but should be considered for its affordability and beauty. Situated on Vietnam’s central coast, Da Nang offers stunning beaches, mountainside pagodas overlooking the sea, and delicious local cuisine.
The cost of living in Da Nang is affordable with low rent prices compared to other Southeast Asian cities such as Bangkok or Singapore. The city also has plenty of co-working spaces available for remote workers looking for a place to get their work done alongside other digital nomads.
One unique aspect of working remotely from Da Nang is its proximity to other destinations in Vietnam. Da Nang is located between the historic city of Hoi An and the bustling city of Hue, making it easy to explore other parts of the country while still having a base in Da Nang.
Playa del Carmen, Mexico
The Perfect Balance Between Work and Play
Located on Mexico’s Caribbean coast, Playa del Carmen is known for its beautiful beaches and vibrant nightlife. However, it’s also a great destination for digital nomads looking for an affordable base with plenty of amenities.
The city has a growing digital nomad community with co-working spaces popping up all over the area. There are also many cafes with free Wi-Fi where remote workers can set up their laptops and get some work done.
One unique aspect of working remotely from Playa del Carmen is its location within Mexico. It’s close to other popular Mexican destinations such as Tulum and Cancun, making it easy to explore other parts of the country while still having a comfortable home base.
Playa del Carmen also offers plenty of opportunities for work-life balance with its stunning beaches and outdoor activities. Whether you’re looking to relax on the beach or take part in water sports like paddleboarding or kayaking, there’s something for everyone in this tropical paradise.
Factors to Consider When Choosing a Digital Nomad Destination
Cost of Living: Finding the Right Balance for Your Budget
One of the most important factors to consider when choosing the best place for digital nomads is the cost of living. This includes everything from accommodation and food to transportation and entertainment. Depending on where you go, you can either stretch your budget or quickly find yourself broke.
When considering the cost of living, it’s important to keep in mind that prices vary greatly among different countries and even within cities. Some digital nomad hotspots, like Bali and Chiang Mai, are known for being very affordable, while other places like Lisbon and Medellin can be slightly more expensive but still offer great value.
To get an accurate idea of the cost of living in a particular city or country, do your research ahead of time by checking out online resources such as Numbeo or Expatistan. Additionally, try reaching out to other digital nomads who have lived or currently live in the area to get a better sense of what expenses you can expect.
Internet Connectivity: The Lifeline for Digital Nomads
As digital nomads are location-independent workers who primarily rely on the Internet for their work and communication needs, internet connectivity is a crucial factor when choosing a destination. Slow or unreliable internet can ruin productivity levels and negatively impact income.
When choosing a place to work remotely, check whether there’s access to high-speed internet connections with reliable uptime. It might also be worth looking into coworking spaces since many offer fast WiFi connections as part of their amenities package.
Travelers should also investigate whether there are backup options available if their primary source goes out unexpectedly – such as mobile data plans that provide ample internet bandwidth with no restrictions on usage limits or hotspot tethering – which would help ensure uninterrupted service despite unforeseen challenges.
Community and Networking Opportunities: Building Relationships Abroad
Digital nomads often travel alone but that doesn’t mean they need to feel lonely. Even when working remotely, they can build connections with other professionals who share their interests and values.
Communities and networking opportunities can help digital nomads grow their businesses, find new clients or partners, learn new skills, or simply make friends while on the road. Coworking spaces are one of the most common places where this happens.
Coworking hubs and digital nomad meetups are great places to network with like-minded individuals. They offer opportunities to exchange knowledge and ideas with other remote workers and entrepreneurs in a relaxed, collaborative setting. Attend events such as workshops or conferences to learn about the latest industry trends, connect with potential collaborators or mentors, and expand your circle of contacts in the digital nomad community.
Safety and Security: Protecting Yourself While Exploring New Territories
Safety should always be a top concern for those traveling abroad but especially for digital nomads who tend to carry expensive electronics. Being aware of local laws, customs, scams, and potential risks is crucial for staying safe.
When choosing your destination as a digital nomad, research local crime statistics before booking accommodation or renting an office space. Familiarize yourself with emergency numbers you might need to use if you’re in danger.
Before you go anywhere new research visa requirements – many countries require documentation beyond just a passport – also ensure your personal insurance covers you internationally & consider taking out extra policies such as trip interruption (for sudden cancellations), health insurance (for unexpected illness) & theft insurance (for lost/damaged laptops, etc.).
By considering these factors when selecting your next digital nomad destination – the cost of living; internet connectivity; community & networking opportunities; safety & security – you can help ensure it will be suitable for both work productivity needs & leisure travel enjoyment!
Additional Tips for Digital Nomads
Finding Accommodation: A Home Away from Home
When it comes to finding accommodation as a digital nomad, there are plenty of options available to suit any budget. From budget hostels and guesthouses to luxury hotels and short-term rentals, the choices can be overwhelming. However, one of the biggest advantages of being a digital nomad is that you have the freedom to work from anywhere in the world.
One of the best resources for finding suitable accommodation is online platforms like Airbnb, Booking.com, or Couchsurfing. These sites offer a wide variety of options ranging from budget apartments to high-end villas and provide an opportunity for you to interact with locals in your chosen destination. Additionally, digital nomads can benefit from co-living spaces such as Roam Co-Living or Selina where they can connect with other like-minded individuals while enjoying comfortable accommodation at affordable prices.
Managing Finances While Traveling: Budgeting Tips for Digital Nomads
As much as being location independent is exciting, it can be financially challenging if not well-managed. From flights and accommodation expenses to food and leisure activities costs, the expenses add up quickly if not well accounted for. To maintain financial stability while traveling, budgeting is key.
To begin with, create a detailed monthly expense plan that includes all anticipated costs such as airfare tickets, accommodation fees (including utilities), meals (groceries or eating out), transport (public or private), leisure activities (entrance fees, etc.), and internet charges among others. As unexpected expenses may arise on the go; always set aside some funds in your savings account which can cater to emergencies.
When managing finances while traveling use apps like Trail Wallet or Money Manager Expense & Budget which help track personal finances on the go ensuring that you stay within your budget thresholds, thereby enabling you to maintain financial stability and eliminate unnecessary spending.
Staying Productive While on the Road: Tips for Maintaining Work-Life Balance
Digital nomads are often faced with the major challenge of maintaining work-life balance while on the go. With so many distractions in new destinations, it is easy to lose focus and get caught up in leisure activities at the expense of delivering work tasks within set deadlines.
To stay focused, it is important to create a schedule that allocates enough time for work and leisure activities. Start by setting clear targets and prioritizing your daily tasks into smaller manageable chunks. This way, you can easily track progress with every task completed, thus avoiding overwhelm. Additionally, consider joining a co-working space or working from cafes or libraries which provide a conducive environment for productivity and eliminate isolation while traveling.
In conclusion, remote work and location independence have led to the rise of the nomad lifestyle. As a result, digital nomad communities are popping up all over the world, making it easier for people to travel while working. We discussed some of the most popular digital nomad destinations such as Bali, Chiang Mai, Lisbon, and Medellin. These locations offer affordable living costs, fast internet connectivity, and great co-working spaces to work from.
Moreover, we explored some lesser-known digital nomad locations like Tbilisi in Georgia, Da Nang in Vietnam, and Playa del Carmen in Mexico. These cities provide a unique cultural experience along with all the amenities that a digital nomad requires.
When choosing the best place for digital nomads to reside in while working remotely or freelancing online, there are several factors to consider such as cost of living, internet connectivity, community and networking opportunities as well as safety and security.
Lastly, I would like to conclude by saying that while there are challenges associated with being a remote worker or a digital nomad traveler such as time management issues or feeling disconnected from coworkers at times; overall it is an incredibly rewarding experience that offers global mobility and work-life balance. With advancements in virtual teams technology creating opportunities for distributed teams and remote collaborations; more people than ever before have access to this lifestyle. If you’re interested in joining this movement then start exploring your options today!
What are the best cities for digital nomads to live and work in?
Which countries offer the best visa options for digital nomads?
What factors should I consider when choosing a location as a digital nomad?
How can I find affordable accommodation as a digital nomad in popular destinations?

domain: geography


text:
The humble sock has undergone some major upgrades as ‘wearable technology’ in the healthcare sector and has emerged as an innovative device used to treat lower limb injuries, foot ulcers and circulatory issues
University of Melbourne PhD student Deepti Aggarwal has developed socks into a tool to aid physiotherapists in the treatment of patients via video consultation.
The socks — known as ‘SoPhy’ — are fitted with sensors to provide data on weight distribution and range of movement, which physiotherapists can assess in real time to provide more comprehensive feedback to patients.
Ms Aggarwal said video consultations were becoming increasingly relied upon for rural and remote patients, however problems arose due to the need to convey subtle information.
“Physiotherapy’s all about movement, so the immediate question that I was wondering was how can physiotherapists see all sorts of movement over video when they see the patients on a 2D screen,” she said.
SoPhy are designed to bridge this gap by providing the information needed.
The news of this development comes shortly after US company Siren launched its own version of the ‘smart sock’ aimed at helping prevent diabetic foot ulcers.
The Siren Sock is made of Neurofabric, which embeds sensors directly into the fabric and is complete with wireless connectivity and a Siren app, allowing for an “easy-to-use consumer [solution]”.
Diabetics are susceptible to foot injuries and sores, due to complications of the disease such as poor circulation and nerve damage, and this can lead to infection and even amputation if left untreated.
Siren co-founder and chief executive Ran Ma began development of the ‘smart sock’ to address this issue through temperature monitoring, to detect early signs of inflammation.
Ms Aggarwal stressed a need for thorough consideration of professional research and opinion as more wearable data collectors, like socks, emerge in the medical field.
“There are many benefits that wearable technologies offer, but we need to understand what kind of data they are giving and how can we make sense of that data,” she said.
“The main question here would be ‘how are you presenting this data that was captured by this sensor?’.
“Anything can become a wearable technology but whether useful or not that’s a big question.”
Founder and chief executive of Israeli medical device start-up ElastiMed Omer Zelka believes the current path of wearable technology is still evolving.
“The field of wearable technology is currently only passive, whether it’s by measuring a user’s pulse, temperature etcetera,” he said.
“The next step in the evolution of wearables has to be made by adding an active component.”
ElastiMed’s compression device, set to be released mid-2019, uses this active approach with Electro Active Polymers.
EAP technology, which changes shape and size in response to electric pulses, was further developed by Mr Zelka into more workable ‘smart materials’.
“I came across the technology a while ago as a personal interest. That interest became a hobby, which in time turned into an obsession, to a point that I’ve built an improvised laboratory at home that looked like a bad episode of Breaking Bad,” Mr Zelka said.
In the company’s first application of smart materials it developed a wrap-around bandage to stimulate circulation through rhythmic contractions, designed for greater comfort and convenience than existing compression methods.
Mr Zelka said not only would the product be an effective treatment for medical conditions such as lymphedema and venous diseases, but also could be used as part of therapy for elite athletes and for general individual wellness to relieve tired legs.
“The key benefit in smart materials is that they are low cost, with high energy efficiency. That means they don’t generate any heat and are completely quiet,” he said.
“These capabilities create an enormous potential in wearables, robotics, energy harvesting, aviation and more.
“In our pipeline we have a couple of future applications already in mind, starting from compression for different body parts, rehabilitation and robotics.”

domain: medical


text:
"Kitty Burns Florey's fifth novel is real, warm, and wonderfully appealing." ~ Library Journal
"This story of obsessive love [is] a very appealing tale." ~ Publishers Weekly
From the publisher: Duet, Kitty Burns Florey's acclaimed fifth novel, is set during the Vietnam years and provides a panoramic view of the 1960s. It’s the story of an aspiring singer named Anna Nolan, and the lonely misfit who's the love of her life, Will Westenberg. The novel follows Anna from her adolescence in a Catholic school in the early 1960s, when the death of a friend brings her and Will together, through her career as a cabaret singer in Boston, and finally her marriage to an idealistic lawyer in New Haven. Layered between the two parts of Anna's story is Will's, as he struggles with a haunting secret from his past, endures a loveless marriage, and desperately tries to gain custody of his son. As the years go by, Anna and Will encounter each other for brief, overwhelming episodes, each obsessed and preoccupied by the other in different ways, until the book's shattering ending. The novel is about the music, the politics, and the texture of life in the '60s, but mostly it's about the power of love to disrupt and redeem.
I had a huge contract for this book, which is a bit of a pot-boiler, but the deal fell through, and Five Questions sank into a hole. It was hauled out and published as an ebook in 2001, and is now available (cheap!) as either a Kindle edition or as a POD paperback. Here's the publisher's blurb: "Wynn Tynan, a young woman growing up in rural Maine, has been raised by her parents to be an artist. When Wynn's idyllic life takes a brief wrong turn--she becomes pregnant as a teenager--her loving but dominating mother is determined that her goals remain intact, and with reluctance, Wynn gives the baby up for adoption. At art school in Boston, she meets Patrick Foss, a sculptor single-mindedly devoted to his work, and knows she has found the love of her life. But fate intervenes with a tragedy from her past, and Wynn's life descends into nightmare."
Script and Scribble: The Rise and Fall of Handwriting
"What in God's name has happened to penmanship? What used to be a craft at which everyone was proficient has degenerated to a little-used arsenal of nearly illegible scrawls and chicken-scratches. It's easy to blame the computer, but, as Kitty Burns Florey demonstrates in her thoughtful, witty and sensible book, the story goes far deeper than that. It touches on the way we think, the way we write, and the way we lead our lives. Read Script & Scribble and be enlightened."
-- Ben Yagoda, author of If You Catch an Adjective, Kill It!
Sister Bernadette's Barking Dog: The Quirky History and Lost Art of Diagramming Sentences
This "charming little book" (Chicago Tribune) now comes with a new Afterword about Sister B. herself, complete with photographs. "A pleasantly discursive and affectionate tribute to an antiquated art." -- Wall Street Journal
The Sleep Specialist
The Sleep Specialist is loosely -- very -- based on my mother's stories about life in Depression-era Los Angeles, where she and my father eloped in 1933 in the rumble seat of a friend's car.
I've moved the setting to New York City in 1934. Robert and May Sinclair arrive in town with two suitcases, Robert’s portable typewriter, and May’s three-way mirror. He’s an aspiring playwright, she’s an actress, and they’re desperately poor. But Robert is hired as the superintendent of a building – twelve dollars a week and a free apartment – and it looks as if the two of them just might survive.
Robert is an insomniac: by day he works frantically on his first play, by night he walks the dark and dangerous streets of the city. He finds himself drawn into the life of a mysterious man named Orson Price – and into an unlikely friendship with Mrs. Amalfi, the Sleep Specialist, who attempts to help Robert overcome his insomnia. Robert’s encounter with the city takes him from an exotic apartment house in Gramercy Park to a seedy hotel in Hell’s Kitchen, from the wards at Bellevue to the literary world of Greenwich Village. As he struggles with emotions that terrify him, Robert is plunged into depths that nearly do him in. But he finishes his play. And, many years later, when he looks back on what happened to him during that desperate time, Robert sees how crucial it was to his development as an artist – and to his pursuit of the life he was meant to live.
Vigil for a Stranger (1994)

domain: literature