<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Dyscalculia and explain in detail? [/INST] Dyscalculia () is a disability resulting in difficulty learning or comprehending arithmetic, such as difficulty in understanding numbers, learning how to manipulate numbers, performing mathematical calculations, and learning facts in mathematics. It is sometimes colloquially referred to "math dyslexia", though this analogy can be misleading as they are distinct syndromes.Dyscalculia is associated with dysfunction in the region around the intraparietal sulcus and potentially also the frontal lobe. Dyscalculia does not reflect a general deficit in cognitive abilities or difficulties with time, measurement, and spatial reasoning. Estimates of the prevalence of dyscalculia range between 3 and 6% of the population. In 2015 it was established that 11% of children with dyscalculia also have ADHD. Dyscalculia has also been associated with Turner syndrome and people who have spina bifida.Mathematical disabilities can occur as the result of some types of brain injury, in which case the term acalculia is used instead of dyscalculia which is of innate, genetic or developmental origin.

Signs and symptoms
The earliest appearance of dyscalculia is typically a deficit in subitizing, the ability to know, from a brief glance and without counting, how many objects there are in a small group. Children as young as five can subitize six objects, especially looking at a die. However, children with dyscalculia can subitize fewer objects and even when correct take longer to identify the number than their age-matched peers. Dyscalculia often looks different at different ages. It tends to become more apparent as children get older; however, symptoms can appear as early as preschool. Common symptoms of dyscalculia are having difficulty with mental math, trouble analyzing time and reading an analog clock, struggle with motor sequencing that involves numbers, and often counting on fingers when adding numbers.

Common symptoms
Dyscalculia is characterized by difficulties with common arithmetic tasks. These difficulties may include:

Difficulty reading analog clocks
Difficulty stating which of two numbers is larger
Sequencing issues
Inability to comprehend financial planning or budgeting, sometimes even at a basic level; for example, estimating the cost of the items in a shopping basket or balancing a checkbook
Visualizing numbers as meaningless or nonsensical symbols, rather than perceiving them as characters indicating a numerical value (hence the misnomer "math dyslexia")
Difficulty with multiplication, subtraction, addition, and division tables, mental arithmetic, etc.
Inconsistent results in addition, subtraction, multiplication and division
When writing, reading and recalling numbers, mistakes may occur in the areas such as: number additions, substitutions, transpositions, omissions, and reversals
Poor memory (retention and retrieval) of math concepts; may be able to perform math operations one day, but draw a blank the next; may be able to do book work but then fails tests
Ability to grasp math on a conceptual level, but an inability to put those concepts into practice
Difficulty recalling the names of numbers, or thinking that certain different numbers "feel" the same (e.g. frequently interchanging the same two numbers for each other when reading or recalling them)
Problems with differentiating between left and right
A "warped" sense of spatial awareness, or an understanding of shapes, distance, or volume that seems more like guesswork than actual comprehension
Difficulty with time, directions, recalling schedules, sequences of events, keeping track of time, frequently late or early
Difficulty reading maps
Difficulty working backwards in time (e.g. What time to leave if needing to be somewhere at X time)
Difficulty reading musical notation
Difficulty with choreographed dance steps
Having particular difficulty mentally estimating the measurement of an object or distance (e.g., whether something is 3 or 6 meters (10 or 20 feet) away)
Inability to grasp and remember mathematical concepts, rules, formulae, and sequences
Inability to concentrate on mentally intensive tasks
Mistaken recollection of names, poor name/face retrieval; may substitute names beginning with same letter.
Some people with dyscalculia also have aphantasia that affects how they can "see" in their minds eye. However, people without dyscalculia also report having this – but it is more prevalent in those with dyslexia and other learning disabilities.

Persistence in children
Although many researchers believe dyscalculia to be a persistent disorder, evidence on the persistence of dyscalculia remains mixed. For instance, in a study done by Mazzocco and Myers (2003), researchers evaluated children on a slew of measures and selected their most consistent measure as their best diagnostic criterion: a stringent 10th-percentile cut-off on the TEMA-2. Even with their best criterion, they found dyscalculia diagnoses for children longitudinally did not persist; only 65% of students who were ever diagnosed over the course of four years were diagnosed for at least two years. The percentage of children who were diagnosed in two consecutive years was further reduced. It is unclear whether this was the result of misdiagnosed children improving in mathematics and spatial awareness as they progressed as normal, or that the subjects who showed improvement were accurately diagnosed, but exhibited signs of a non-persistent learning disability.

Persistence in adults
There are very few studies of adults with dyscalculia who have had a history of it growing up, but such studies have shown that it can persist into adulthood. It can affect major parts of an adults life. Most adults with dyscalculia have a hard time processing math at a 4th grade level. For 1st-4th grade level, many adults will know what to do for the math problem, but they will often get them wrong because of "careless errors", although they are not careless when it comes to the problem. The adults cannot process their errors on the math problems or may not even recognize that they have made these errors. Visual-spatial input, auditory input, and touch input will be affected due to these processing errors. Dyscalculics may have a difficult time adding numbers in a column format because their mind can mix up the numbers, and it is possible that they may get the same (wrong) answer twice due to their mind processing the problem incorrectly. Dyscalculics can have problems determining differences in different coins and their size or giving the correct amount of change and if numbers are grouped together, it is possible that they cannot determine which has less or more. If a dyscalculic is asked to choose the greater of two numbers, with the lesser number in a larger font than the greater number, they may take the question literally and pick the number with the bigger font. Adults with dyscalculia have a tough time with directions while driving and with controlling their finances, which causes difficulties on a day-to-day basis.

College students or other adult learners
College students particularly may have a difficult time due to the fast pace and change in difficulty of the work they are given. As a result of this, students may develop much anxiety and frustration. After dealing with their anxiety for a long time, students can become averse to math and try to avoid it as much as possible, which may result in lower grades in math courses. (That said, students with dyscalculia can also do exceptionally well in writing, reading, and speaking.)

Causes
Both domain-general and domain-specific causes have been put forth. With respect to pure developmental dyscalculia, domain-general causes are unlikely as they should not impair ones ability in the numerical domain without also affecting other domains such as reading.Two competing domain-specific hypotheses about the causes of developmental dyscalculia have been proposed – the magnitude representation (or number module deficit hypothesis) and the access deficit hypothesis.

Magnitude representation deficit
Dehaenes "number sense" theory suggests that approximate numerosities are automatically ordered in an ascending manner on a mental number line. The mechanism to represent and process non-symbolic magnitude (e.g., number of dots) is often known as the "approximate number system" (ANS), and a core deficit in the precision of the ANS, known as the "magnitude representation hypothesis" or "number module deficit hypothesis", has been proposed as an underlying cause of developmental dyscalculia.In particular, the structural features of the ANS is theoretically supported by a phenomenon called the "numerical distance effect", which has been robustly observed in numerical comparison tasks. Typically developing individuals are less accurate and slower in comparing pairs of numbers closer together (e.g., 7 and 8) than further apart (e.g., 2 and 9). A related "numerical ratio effect" (in which the ratio between two numbers varies but the distance is kept constant, e.g., 2 vs. 5 and 4 vs. 7) based on the Webers law has also been used to further support the structure of the ANS. The numerical ratio effect is observed when individuals are less accurate and slower in comparing pairs of numbers that have a larger ratio (e.g., 8 and 9, ratio = 8/9) than a smaller ratio (2 and 3; ratio = 2/3). A larger numerical distance or ratio effect with comparison of sets of objects (i.e., non-symbolic) is thought to reflect a less precise ANS, and the ANS acuity has been found to correlate with math achievement in typically developing children and also in adults.More importantly, several behavioral studies have found that children with developmental dyscalculia show an attenuated distance/ratio effect than typically developing children. Moreover, neuroimaging studies have also provided additional insights even when behavioral difference in distance/ratio effect might not be clearly evident. For example, Gavin R. Price and colleagues found that children with developmental dyscalculia showed no differential distance effect on reaction time relative to typically developing children, but they did show a greater effect of distance on response accuracy. They also found that the right intraparietal sulcus in children with developmental dyscalculia was not modulated to the same extent in response to non-symbolic numerical processing as in typically developing children. With the robust implication of the intraparietal sulcus in magnitude representation, it is possible that children with developmental dyscalculia have a weak magnitude representation in the parietal region. Yet, it does not rule out an impaired ability to access and manipulate numerical quantities from their symbolic representations (e.g., Arabic digits).

Moreover, findings from a cross-sectional study suggest that children with developmental dyscalculia might have a delayed development in their numerical magnitude representation by as much as five years. However, the lack of longitudinal studies still leaves the question open as to whether the deficient numerical magnitude representation is a delayed development or impairment.

Access deficit hypothesis
Rousselle & Noël propose that dyscalculia is caused by the inability to map preexisting representations of numerical magnitude onto symbolic Arabic digits. Evidence for this hypothesis is based on research studies that have found that individuals with dyscalculia are proficient on tasks that measure knowledge of non-symbolic numerical magnitude (i.e., non-symbolic comparison tasks) but show an impaired ability to process symbolic representations of number (i.e., symbolic comparison tasks). Neuroimaging studies also report increased activation in the right intraparietal sulcus during tasks that measure symbolic but not non-symbolic processing of numerical magnitude. However, support for the access deficit hypothesis is not consistent across research studies.

Diagnosis
At its most basic level, dyscalculia is a learning disability affecting the normal development of arithmetic skills.A consensus has not yet been reached on appropriate diagnostic criteria for dyscalculia. Mathematics is a specific domain that is complex (i.e. includes many different processes, such as arithmetic, algebra, word problems, geometry, etc.) and cumulative (i.e. the processes build on each other such that mastery of an advanced skill requires mastery of many basic skills). Thus dyscalculia can be diagnosed using different criteria, and frequently is; this variety in diagnostic criteria leads to variability in identified samples, and thus variability in research findings regarding dyscalculia.

Other than using achievement tests as diagnostic criteria, researchers often rely on domain-specific tests (i.e. tests of working memory, executive function, inhibition, intelligence, etc.) and teacher evaluations to create a more comprehensive diagnosis. Alternatively, fMRI research has shown that the brains of the neurotypical children can be reliably distinguished from the brains of the dyscalculic children based on the activation in the prefrontal cortex. However, due to the cost and time limitations associated with brain and neural research, these methods will likely not be incorporated into diagnostic criteria despite their effectiveness.

Types
Research on subtypes of dyscalculia has begun without consensus; preliminary research has focused on comorbid learning disorders as subtyping candidates. The most common comorbidity in individuals with dyscalculia is dyslexia. Most studies done with comorbid samples versus dyscalculic-only samples have shown different mechanisms at work and additive effects of comorbidity, indicating that such subtyping may not be helpful in diagnosing dyscalculia. But there is variability in results at present.Due to high comorbidity with other disabilities such as dyslexia and ADHD, some researchers have suggested the possibility of subtypes of mathematical disabilities with different underlying profiles and causes. Whether a particular subtype is specifically termed "dyscalculia" as opposed to a more general mathematical learning disability is somewhat under debate in the scientific literature.

Semantic memory: This subtype often coexists with reading disabilities such as dyslexia and is characterized by poor representation and retrieval from long-term memory. These processes share a common neural pathway in the left angular gyrus, which has been shown to be selective in arithmetic fact retrieval strategies and symbolic magnitude judgments. This region also shows low functional connectivity with language-related areas during phonological processing in adults with dyslexia. Thus, disruption to the left angular gyrus can cause both reading impairments and difficulties in calculation. This has been observed in individuals with Gerstmann syndrome, of which dyscalculia is one of constellation of symptoms.
Procedural concepts: Research by Geary has shown that in addition to increased problems with fact retrieval, children with math disabilities may rely on immature computational strategies. Specifically, children with mathematical disabilities showed poor command of counting strategies unrelated to their ability to retrieve numeric facts. This research notes that it is difficult to discern whether poor conceptual knowledge is indicative of a qualitative deficit in number processing or simply a delay in typical mathematical development.
Working memory: Studies have found that children with dyscalculia showed impaired performance on working memory tasks compared to neurotypical children. Furthermore, research has shown that children with dyscalculia have weaker activation of the intraparietal sulcus during visuospatial working memory tasks. Brain activity in this region during such tasks has been linked to overall arithmetic performance, indicating that numerical and working memory functions may converge in the intraparietal sulcus. However, working memory problems are confounded with domain-general learning difficulties, thus these deficits may not be specific to dyscalculia but rather may reflect a greater learning deficit. Dysfunction in prefrontal regions may also lead to deficits in working memory and other executive function, accounting for comorbidity with ADHD.Studies have also shown indications of causes due to congenital or hereditary disorders, but evidence of this is not yet concrete.

Treatment
To date, very few interventions have been developed specifically for individuals with dyscalculia. Concrete manipulation activities have been used for decades to train basic number concepts for remediation purposes. This method facilitates the intrinsic relationship between a goal, the learners action, and the informational feedback on the action. A one-to-one tutoring paradigm designed by Lynn Fuchs and colleagues which teaches concepts in arithmetic, number concepts, counting, and number families using games, flash cards, and manipulables has proven successful in children with generalized math learning difficulties, but intervention has yet to be tested specifically on children with dyscalculia. These methods require specially trained teachers working directly with small groups or individual students. As such, instruction time in the classroom is necessarily limited. For this reason, several research groups have developed computer adaptive training programs designed to target deficits unique to dyscalculic individuals.Software intended to remediate dyscalculia has been developed. While computer adaptive training programs are modeled after one-to-one type interventions, they provide several advantages. Most notably, individuals are able to practice more with a digital intervention than is typically possible with a class or teacher. As with one-to-one interventions, several digital interventions have also proven successful in children with generalized math learning difficulties. Räsänen and colleagues have found that games such as The Number Race and Graphogame-math can improve performance on number comparison tasks in children with generalized math learning difficulties.Several digital interventions have been developed for dyscalculics specifically. Each attempts to target basic processes that are associated with maths difficulties. Rescue Calcularis was one early computerized intervention that sought to improve the integrity of and access to the mental number line. Other digital interventions for dyscalculia adapt games, flash cards, and manipulables to function through technology.While each intervention claims to improve basic numerosity skills, the authors of these interventions do admit that repetition and practice effects may be a factor involved in reported performance gains. An additional criticism is that these digital interventions lack the option to manipulate numerical quantities. While the previous two games provide the correct answer, the individual using the intervention cannot actively determine, through manipulation, what the correct answer should be. Butterworth and colleagues argued that games like The Number Bonds, which allows an individual to compare different sized rods, should be the direction that digital interventions move toward. Such games use manipulation activities to provide intrinsic motivation toward content guided by dyscalculia research. One of these serious games is Meister Cody – Talasia, an online training that includes the CODY Assessment – a diagnostic test for detecting dyscalculia. Based on these findings, Dybuster Calcularis was extended by adaptation algorithms and game forms allowing manipulation by the learners. It was found to improve addition, subtraction and number line tasks, and was made available as Dybuster Calcularis.A study used transcranial direct current stimulation (TDCS) to the parietal lobe during numerical learning and demonstrated selective improvement of numerical abilities that was still present six months later in typically developing individuals. Improvement were achieved by applying anodal current to the right parietal lobe and cathodal current to the left parietal lobe and contrasting it with the reverse setup. When the same research group used tDCS in a training study with two dyscalculic individuals, the reverse setup (left anodal, right cathodal) demonstrated improvement of numerical abilities.

Epidemiology
Dyscalculia is thought to be present in 3–6% of the general population, but estimates by country and sample vary somewhat. Many studies have found prevalence rates by gender to be equivalent. Those that find gender difference in prevalence rates often find dyscalculia higher in females, but some few studies have found prevalence rates higher in males.

History
The term dyscalculia was coined in the 1940s, but it was not completely recognized until 1974 by the work of Czechoslovakian researcher Ladislav Kosc. Kosc defined dyscalculia as "a structural disorder of mathematical abilities." His research proved that the learning disability was caused by impairments to certain parts of the brain that control mathematical calculations and not because symptomatic individuals were mentally handicapped. Researchers now sometimes use the terms "math dyslexia" or "math learning disability" when they mention the condition. Cognitive disabilities specific to mathematics were originally identified in case studies with patients who experienced specific arithmetic disabilities as a result of damage to specific regions of the brain.  More commonly, dyscalculia occurs developmentally as a genetically linked learning disability which affects a persons ability to understand, remember, or manipulate numbers or number facts (e.g., the multiplication tables). The term is often used to refer specifically to the inability to perform arithmetic operations, but is also defined by some educational professionals and cognitive psychologists such as Stanislas Dehaene and Brian Butterworth as a more fundamental inability to conceptualize numbers as abstract concepts of comparative quantities (a deficit in "number sense"), which these researchers consider to be a foundational skill upon which other mathematics abilities build. Symptoms of dyscalculia include the delay of simple counting, inability to memorize simple arithmetic facts such as adding, subtracting, etc. There are few known symptoms because little research has been done on the topic.

Etymology
The term dyscalculia dates back to at least 1949.Dyscalculia comes from Greek and Latin and means "counting badly". The prefix "dys-" comes from Greek and means "badly". The root "calculia" comes from the Latin "calculare", which means "to count"; it is also a cognate of "calculation" and "calculus".

See also
References
Further reading
Abeel, Samantha (2003). My thirteenth winter: a memoir. New York: Orchard Books. ISBN 978-0-439-33904-9. OCLC 51536704.
Ardila A, Rosselli M (December 2002). "Acalculia and dyscalculia" (PDF). Neuropsychol Rev. 12 (4): 179–231. doi:10.1023/a:1021343508573. PMID 12539968. S2CID 2617160.
Tony Attwood (2002). Dyscalculia in Schools: What it is and What You Can Do. First & Best in Education Ltd. ISBN 978-1-86083-614-5. OCLC 54991398.
Butterworth, Brian; Yeo, Dorian (2004). Dyscalculia Guidance: Helping Pupils with Specific Learning Difficulties in Maths. London: NferNelson. ISBN 978-0-7087-1152-1. OCLC 56974589.
Campbell, Jamie I. D. (2004). Handbook of Mathematical Cognition. Psychology Press (UK). ISBN 978-1-84169-411-5. OCLC 644354765.
Brough, Mel; Henderson, Anne; Came, Fil (2003). Working with dyscalculia: recognising dyscalculia: overcoming barriers to learning in maths. Santa Barbara, Calif: Learning Works. ISBN 978-0-9531055-2-6. OCLC 56467270.
Chinn, Stephen J. (2004). The Trouble with Maths: A Practical Guide to Helping Learners with Numeracy Difficulties </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Foster care and explain in detail? [/INST] Foster care is a system in which a minor has been placed into a ward, group home (residential child care community, treatment center, etc.), or private home of a state-certified caregiver, referred to as a "foster parent" or with a family member approved by the state. The placement of the child is normally arranged through the government or a social service agency. The institution, group home, or foster parent is compensated for expenses unless with a family member. In some states, relative or "Kinship" caregivers of children who are wards of the state are provided with a financial stipend.
The state, via the family court and child protective services agency, stand in loco parentis to the minor, making all legal decisions while the foster parent is responsible for the day-to-day care of the minor.
Scholars and activists are concerned about the efficacy of the foster care services provided by NGOs. Specifically, this pertains to poor retention rates of social workers. Poor retention rates are attributed to being overworked in an emotionally draining field that offers minimal monetary compensation. The lack of professionals pursuing a degree in social work coupled with poor retention rates in the field has led to a shortage of social workers and created large caseloads for those who choose to work and stay in the field.   The efficacy of caseworker retention also affects the overall ability to care for clients. Low staffing leads to data limitations that infringe on caseworkers ability to adequately serve clients and their families. Foster care is correlated with a range of negative outcomes compared to the general population. Children in foster care have a high rate of ill health, particularly psychiatric conditions such as anxiety, depression, and eating disorders. One third of foster children in a US study reported abuse from a foster parent or other adult in the foster home. Nearly half of foster children in the US become homeless when they reach the age of 18, and the poverty rate is three times higher among foster care alumni than in the general population.

By country
Australia
In Australia foster care was known as "boarding-out". Foster care had its early stages in South Australia in 1867 and stretched to the second half of the 19th century. It is said that the system was mostly run by women until the early 20th century. Then the control was centered in many state childrens departments. "Although boarding-out was also implemented by non-government[al] child rescue organizations, many large institutions remained. These institutions assumed an increasing importance from the late 1920s when the system went into decline." The system was re-energized in the postwar era, and in the 1970s. The system is still the main structure for "out-of-home care." The system took care of both local and foreign children. "The first adoption legislation was passed in Western Australia in 1896, but the remaining states did not act until the 1920s, introducing the beginnings of the closed adoption that reached it peak in the period 1940–1975. New baby adoption dropped dramatically from the mid-1970s, with the greater tolerance of and support for single mothers".

Cambodia
Foster care in Cambodia is relatively new as an official practice within the government. However, despite a later start, the practice is currently making great strides within the country. Left with a large number of official and unofficial orphanages from the 1990s, the Cambodian government conducted several research projects in 2006 and 2008, pointing to the overuse of orphanages as a solution for caring for vulnerable children within the country. Most notably, the studies found that the percentage of children within orphanages that had parents approached 80%. At the same time, local NGOs like "Children In Families" began offering limited foster care services within the country. In the subsequent years, the Cambodian government began implementing policies that required the closure of some orphanages and the implementation of minimum standards for residential care institutions. These actions lead to an increase in the number of NGOs providing foster care placements and helped to set the course for care reform around the country. As of 2015, the Cambodian government is working with UNICEF, USAID, several governments, and many local NGOs in continuing to build the capacity for child protection and foster care within the Kingdom.

Canada
Foster children in Canada are known as permanent wards, (crown wards in Ontario). A ward is someone, in this case a child, placed under protection of a legal guardian and are the legal responsibility of the government. Census data from 2011 counted children in foster care for the first time, counting 47,885 children in care. The majority of foster children – 29,590, or about 62 per cent – were aged 14 and under. The wards remain under the care of the government until they "age out of care." All ties are severed from the government and there is no longer any legal responsibility toward the youth. This age is different depending on the province.

Israel
In December 2013, the Israeli Knesset approved a bill co-drafted by the Israel National Council for the Child to regulate the rights and obligations of participants in the foster care system in Israel.

Japan
The idea of foster care or taking in abandoned children actually came about around 1392-1490s in Japan. The foster care system in Japan is similar to the Orphan Trains because Brace thought the children would be better off on farms. The people in Japan thought the children would do better on farms rather than living in the "dusty city." The families would often send their children to a farm family outside the village and only keep their oldest son. The farm families served as the foster parents and they were financially rewarded for taking in the younger siblings. "It was considered an honor to be chosen as foster parents, and selection greatly depended on the familys reputation and status within the village". Around 1895 the foster care program became more like the system used in the United States because the Tokyo Metropolitan Police sent children to a hospital where they would be "settled". Problems emerged in this system, such as child abuse, so the government started phasing it out and "began increasing institutional facilities". In 1948 the Child Welfare Law was passed, increasing official oversight, and creating better conditions for the children to grow up in.

United Kingdom
In the United Kingdom, foster care and adoption has always been an option, "in the sense of taking other peoples children into their homes and looking after them on a permanent or temporary basis." Although, nothing about it had a legal foundation, until the 20th century. The UK had "wardship," the family taking in the child had custody by the Chancery Court. Wardship was not used very often because it did not give the guardian "parental rights." In the 19th century came a "series of baby farming scandals." At the end of the 19th century they started calling it "boarding-out" like they did in Australia. They started placing the children in orphanages and workhouses as well. "The First World War saw an increase in organized adoption through adoption societies and child rescue organizations, and pressure grew for adoption to be given legal status." The first laws based on adoption and foster care were passed in 1926. "The peak number of adoptions was in 1968, since then there has been an enormous decline in adoption in the United Kingdom. The main reasons for children being adopted in the United Kingdom had been unmarried mothers giving up their children for adoption and stepparents adopting their new partners children".

United States
In the United States, foster care started as a result of the efforts of Charles Loring Brace. "In the mid 19th Century, some 30,000 homeless or neglected children lived in the New York City streets and slums." Brace took these children off the streets and placed them with families in most states in the country. Brace believed the children would do best with a Christian farm family. He did this to save them from "a lifetime of suffering" He sent these children to families by train, which gave the name The Orphan Train Movement. "This lasted from 1853 to the early 1890s  and transported more than 120,000 250,000? children to new lives." When Brace died in 1890, his sons took over his work of the Childrens Aid Society until they retired. The Childrens Aid Society created "a foster care approach that became the basis for the federal Adoption and Safe Families Act of 1997" called Concurrent Planning. This greatly impacted the foster care system.
From August 1999 - August 2019, 9,073,607 American children have been removed from their families and placed in foster homes according to the federal government Adoption and Foster Care Analysis and Reporting System.As last reported in August 2019, 437,238 children nationally were removed from their families and placed in foster homes according to the federal government Adoption and Foster Care Analysis and Reporting System.- 24% of foster children are between the ages of 0 and 2- 18% of foster children are between the ages of 3 and 5- 28% of foster children are between the ages of 6 and 12- 40% of foster children are between the ages of 13 and 21- Average # of birthdays a child spends in foster care: 2 - 22% of children had three or more placements during a length of 20 months in foster care.- 91% of foster children under the age of 2 are adopted.

France
In France, foster families are called familles daccueil (literally "welcome families"). Foster homes must obtain an official approval from the government in order to welcome a minor or an elderly person. In order to receive this approval they must follow a training and their home is inspected to be sure it is safe and healthy. In 2017, 344 000 minors and 15000 elderly persons were welcomed in foster homes.

Placement
Family-based foster care is generally preferred to other forms of out of home care. Foster care is intended to be a short-term solution until a permanent placement can be made. In most states, the primary objective is to reconcile children with the biological parents. However, if the parents are unable or unwilling to care for the child, or if the child is an orphan, then the first choice of adoptive parents is a relative such as an aunt, uncle or grandparent, known as kinship care. Most kinship care is done informally, without the involvement of a court or public organization. However, in the United States, formal kinship care is increasingly common. In 2012, a quarter of all children in formal foster care were placed with relatives instead of being placed into the system.If no related family member is willing or able to adopt, the next preference is for the child to be adopted by the foster parents or by someone else involved in the childs life (such as a teacher or coach). This is to maintain continuity in the childs life. If neither above option are available, the child may be adopted by someone who is a stranger to the child.
If none of these options are viable, the plan for the minor may be to enter OPPLA (Other Planned Permanent Living Arrangement). This option allows the child to stay in custody of the state and the child can stay placed in a foster home, with a relative or a long-term care facility, such as a residential child care community or, for children with development disabilities, physical disabilities or mental disabilities, a treatment center.
671,000 children were served by the foster care system in the United States in 2015. "After declining more than 20 percent between FY 2006 and FY 2012 to a low of 397,000, the number of children in foster care on the last day of the fiscal year increased to 428,000 in FY 2015, with a slightly higher percent change from 2014 to 2015 (3.3%) than observed from 2013 to 2014 (3.2%)." Since FY 2012, the number of children in foster care at the end of each FY has steadily increased.The median amount of time a child spent in foster care in the U.S. in 2015 was 13.5 months. That year, 74% of children spent less than two years in foster care, while 13% were in care for three or more years. Of the estimated 427,910 children in foster care on September 30, 2015: 43 percent were White, 24 percent were African-American, 21 percent were Hispanic (of any race), 10 percent were other races or multiracial, and 2 percent were unknown or unable to be determined.Children may enter foster care voluntarily or involuntarily. Voluntary placement may occur when a biological parent or lawful guardian is unable to care for a child. Involuntary placement occurs when a child is removed from their biological parent or lawful guardian due to the risk or actual occurrence of physical or psychological harm, or if the child has been orphaned. In the US, most children enter foster care due to neglect. If a biological parent or legal guardian is unwilling to care for a child, the child is deemed to be dependent and is placed under the care of the child protection agency. The policies regarding foster care as well as the criteria to be met in order to become a foster parent vary according to legal jurisdiction.
Especially egregious failures of child protective services often serve as a catalyst for increased removal of children from the homes of biological parents. An example is the brutal torture and murder of 17-month-old Peter Connelly, a British toddler who died in London Borough of Haringey, North London after suffering more than 50 severe injuries over an eight-month period, including eight broken ribs and a broken back. Throughout the period of time in which he was being tortured, he was repeatedly seen by Haringey Childrens services and NHS health professionals. Haringey Childrens services already failed ten years earlier in the case of Victoria Climbié. In the time since his death, in 2007, cases have reached a record rate in England surpassing 10,000 in the reporting year ending in March 2012.

Abuse and negligence
From 1993 through 2002 there were 107 recorded deaths; there are approximately 400,000 children in out-of-home care, in the United States. Almost 10% of children in foster care have stayed in foster care for five or more years. Nearly half of all children in foster care have chronic medical problems. 8% of all children in foster care have serious emotional problems, 11% of children exiting foster care aged out of the system, in 2011. Children in foster care experience high rates of child abuse, emotional deprivation, and physical neglect. In one study in the United Kingdom "foster children were 7–8 times, and children in residential care 6 times more likely to be assessed by a pediatrician for abuse than a child in the general population". A study of foster children in Oregon and Washington State found that nearly one third reported being abused by a foster parent or another adult in a foster home. The "Parent Trauma Response Questionnaire" states that parental overprotection can be just as harmful psychologically as neglect.

Development
As of 2019, the majority of children in the foster care system were under 8 years of age. These early years are quite important for the physical and mental development of children. More specifically, these early years are most important for brain development. Stressful and traumatic experiences have been found to have long-term negative consequences for the brain development in children whereas talking, singing, and playing can help encourage brain growth. Since the majority of children are removed from their homes due to neglect, this means that many of these children did not experience stable and stimulating environments to help promote this necessary growth. In a research study conducted at the University of Minnesota, researchers found that children placed in non-parental homes, such as foster homes, showed significant behavior problems and higher levels of internalizing problems in comparison to children in traditional families and even children who were mistreated by caregivers. According to an article written by Elizabeth Curry titled The five things you should know about how orphanage life affects children  they state that a child who has lived in an orphanage or a home for multiple children, they will have learned survival skills but lack family skills due to them never understanding permanency.

Medical and psychiatric disorders
A higher prevalence of physical, psychological, cognitive and epigenetic disorders for children in foster care has been established in studies in various countries. The Casey Family Programs Northwest Foster Care Alumni Study was a fairly extensive study of various aspects of children who had been in foster care.
Individuals who were in foster care experience higher rates of physical and psychiatric morbidity than the general population and suffer from not being able to trust and that can lead to placements breaking down.In the Casey study of foster children in Oregon and Washington state, they were found to have double the incidence of depression, 20% as compared to 10% and were found to have a higher rate of posttraumatic stress disorder (PTSD) than combat veterans with 25% of those studied having PTSD. Children in foster care have a higher probability of having attention deficit hyperactivity disorder (ADHD), and deficits in executive functioning, anxiety as well as other developmental problems.These children experience higher degrees of incarceration, poverty, homelessness, and suicide. Studies in the U.S. have suggested that some foster care placements may be more detrimental to children than remaining in a troubled home, but a more recent study suggested that these findings may have been affected by selection bias, and that foster care has little effect on behavioral problems.

Neurodevelopment
Foster children have elevated levels of cortisol, a stress hormone, in comparison to children raised by their biological parents. Elevated cortisol levels can compromise the immune system. (Harden BJ, 2004). Most of the processes involved in typical neurodevelopment are predicated upon the establishment of close nurturing relationships and environmental stimulation. Negative environmental influences during this critical period of brain development can have lifelong consequences.

Post traumatic stress disorder
Children in foster care have a higher incidence of posttraumatic stress disorder (PTSD). In one study, 60% of children in foster care who had experienced sexual abuse had PTSD, and 42% of those who had been physically abused met the PTSD criteria. PTSD was also found in 18% of the children who were not abused. These children may have developed PTSD due to witnessing violence in the home. (Marsenich, 2002).
In order to figure out if a child is going through PTSD, there is a PTSD module, the anxiety disorder interview. This is considered a  reliable resource for establishing if a child is going through post traumatic stress disorder due to physical, sexual, or mental abuse.In a study conducted in Oregon and Washington state, the rate of PTSD in adults who were in foster care for one year between the ages of 14–18 was found to be higher than that of combat veterans, with 25 percent of those in the study meeting the diagnostic criteria as compared to 12–13 percent of Iraq war veterans and 15 percent of Vietnam war veterans, and a rate of 4% in the general population. The recovery rate for foster home alumni was 28.2% as opposed to 47% in the general population.
"More than half the study participants reported clinical levels of mental illness, compared to less than a quarter of the general population".

Eating disorders
Foster children are at increased risk for a variety of eating disorders in comparison to the general population. In a study done in the United Kingdom, 35% of foster children experienced an increase in Body Mass Index (BMI) once in care. Food Maintenance Syndrome is characterized by a set of aberrant eating behaviors of children in foster care. It is "a pattern of excessive eating and food acquisition and maintenance behaviors without concurrent obesity"; it resembles "the behavioral correlates of Hyperphagic Short Stature". It is hypothesized that this syndrome is triggered by the stress and maltreatment foster children are subjected to, it was prevalent amongst 25 percent of the study group in New Zealand. Bulimia nervosa is seven times more prevalent among former foster children than in the general population.

Poverty and homelessness
Nearly half of foster children in the U.S. become homeless when they turn 18. One of every 10 foster children stays in foster care longer than seven years, and each year about 15,000 reach the age of majority and leave foster care without a permanent family—many to join the ranks of the homeless or to commit crimes and be imprisoned.Three out of 10 of the United States homeless are former foster children. According to the results of the Casey Family Study of Foster Care Alumni, up to 80 percent are doing poorly—with a quarter to a third of former foster children at or below the poverty line, three times the national poverty rate. Very frequently, people who are homeless had multiple placements as children: some were in foster care, but others experienced "unofficial" placements in the homes of family or friends.
Individuals with a history of foster care tend to become homeless at an earlier age than those who were not in foster care. The length of time a person remains homeless is longer in individuals who were in foster care.

Suicide-death rate
Children in foster care are at a greater risk of suicide. The increased risk of suicide is still prevalent after leaving foster care. In a small study of twenty-two Texan youths who aged out of the system, 23 percent had a history of suicide attempts.A Swedish study utilizing the data of almost one million people including 22,305 former foster children who had been in care prior to their teens, concluded:

Former child welfare clients were in year of birth and sex standardised risk ratios (RRs) four to five times more likely than peers in the general population to have been hospitalised for suicide attempts....Individuals who had been in long-term foster care tended to have the most dismal outcome...former child welfare/protection clients should be considered a high-risk group for suicide attempts and severe psychiatric morbidity.

Death rate
Children in foster care have an overall higher mortality rate than children in the general population. A study conducted in Finland among current and former foster children up to age 24 found a higher mortality rate due to substance abuse, accidents, suicide and illness. The deaths due to illness were attributed to an increased incidence of acute and
chronic medical conditions and developmental delays among children in foster care.
Georgia Senator Nancy Schaefer published a report "The Corrupt Business of Child Protective Services" stating: "The National Center on Child Abuse and Neglect in 1998 reported that six times as many children died in foster care than in the general public and that once removed to official "safety", these children are far more likely to suffer abuse, including sexual molestation than in the general population".

Academic prospects
Educational outcomes of ex-foster children in the Northwest Alumni Study:
56% completed high school compared to 82% of the general population, although an additional 29% of former foster children received a G.E.D. compared to an additional 5% of the general population.
42.7% completed some education beyond high school.
20.6% completed any degree or certificate beyond high school
16.1% completed a vocational degree; 21.9% for those over 25.
1.8% complete a bachelors degree, 2.7% for over 25, the completion rate for the general population in the same age group is 24%, a sizable difference.The study reviewed case records for 659 foster care alumni in Northwest USA, and interviewed 479 of them
between September 2000 and January 2002.

Higher Education
Approximately 10% of foster youth make it to college and of those 10%, only about 3% actually graduate and obtain a 4-year degree. Although the number of foster youth who are starting at a 4-year university after high school has increased over the years, the number of youth who graduate from college continues to remain stable. A study of 712 youth in California, the results revealed that foster care youth are fives times less likely to attend college than youth who do not go through foster care. There are different resources that offer both financial and emotional support for foster youth to continue their education. Simultaneously, there are also many barriers that make getting to a college or university difficult.
Borton describes some of the barriers youth face in her article, Barriers to Post-Secondary Enrollment for Former Foster Youth. A few of those barriers include financial hurdles, navigating through the application process with little to no support, and lack of housing.Many studies have shown that there are a few factors that have seemingly played a role in the success of foster youth making it to and graduating from a college or university. While having financial resources for foster youth is a huge help, there are other components to look at. Beginning with having support for these youth at the high school level. In order for foster youth to obtain a college degree, they must enroll at a university first.
Out of the different factors that play in increasing college enrollment such as youth participating in extended foster care, reading ability, etc., youth who received assistance or had supportive relationships from adults, were more likely than youth who did not have supportive relationships, to enroll at a university.At colleges across the nation, there are programs that are specifically put in place to help youth who have aged out of the foster care system and continued into higher education. These programs often help youth financially by giving them supplemental funds and providing support through peer mentor programs or academic counseling services. While funding is an important key in helping get through college, it hasnt been found as the only crucial component in aiding a youths success.
A study done by Jay and colleagues provides insight on what youth view as important in helping them thrive on a college campus. The study, which had a sample of 51 foster youth, used Conceptual Mapping to break down the different components of support that may be important for youth to receive on a college campus. It is important to take in the different factors that can be helpful for youth at a university and to look beyond providing financial support.

Psychotropic medication use
Studies have revealed that youth in foster care covered by Medicaid insurance receive psychotropic medication at a rate that was 3 times higher than that of Medicaid-insured youth who qualify by low family income. In a review (September 2003 to August 2004) of the medical records of 32,135 Texas foster care 0–19 years old, 12,189 were prescribed psychotropic medication, resulting in an annual prevalence of 37.9% of these children being prescribed medication. 41.3% received 3 different classes of these drugs during July 2004, and 15.9% received 4 different classes. The most frequently used medications were antidepressants (56.8%), attention-deficit/hyperactivity disorder drugs (55.9%), and antipsychotic agents (53.2%). The study also showed that youth in foster care are frequently treated with concomitant psychotropic medication, for which sufficient evidence regarding safety and effectiveness is not available.The use of expensive, brand name, patent protected medication was prevalent. In the case of SSRIs the use of the most expensive medications was noted to be 74%; in the general market only 28% are for brand name SSRIs vs generics.  The average out-of-pocket expense per prescription was $34.75 for generics and $90.17 for branded products, a $55.42, difference.

Therapeutic intervention
Children in the child welfare system have often experienced significant and repeated traumas and having a background in foster homes—especially in instances of sexual abuse—can be the precipitating factor in a wide variety of psychological and cognitive deficits it may also serve to obfuscate the true cause of underlying issues. The foster care experience may have nothing to do with the symptoms, or on the other hand, a disorder may be exacerbated by having a history of foster care and attendant abuses. The human brain however has been shown to have a fair degree of neuroplasticity. and adult neurogenesis has been shown to be an ongoing process.Multidimensional Treatment Foster Care (MTFC), also referred to as Treatment Foster Care Oregon (TFCO) and Treatment Foster Care (TFC) is a community-based intervention that was created in 1983 by Dr. Patricia Chamberlain and her associated colleagues with the initial design intended to offer a replacement for group facilities. MTFC has differing approaches for different age groups. Preschoolers receive “a behavior-management approach and intensively trains, supervises, and supports foster caregivers to provide positive adult support and consistent limit setting” coupled with “coordinated interventions with the child’s biological parents.” MTFC for adolescence consists of individual placement with an intensely trained foster family providing “coordinated interventions in the home, with peers, [and] in educational settings.” MTFC has been shown to provide better results than group facilities and proves to be more cost effective. Reports show that Multidimensional treatment has effective results in reducing depression, arrest rates, deviant peer affiliations, placement disruption, and pregnancy rates while having positive replication trials. It is one method that attempts to incorporate trauma- and violence-informed care into its design.Researchers have faced difficulty when it comes to accurately assessing what makes MTFC and other similar programs that involve multiple levels of intervention successful. It seems to remain in a "black box"  scenario where it is unsure what aspect of the treatment plan is actually producing positive effects. Multiple peer-reviewed research articles on foster care programs point out a lack of research effectively evaluating the outcomes of specific foster care programs, calling for more complete assessments to be conducted  in order to properly compare outcomes between treatment plans and evaluate what practices in MTFC are most effective. Ethical concerns have also been raised by Therese Åström and other associated researchers when conducting a systematic review on behalf of the Swedish Agency for Health Technology Assessment and Assessment of Social Services in 2018, noting that on the one hand MTFC is evaluated as effective, however, it tends to be implemented in a way that diminishes the childs agency.

Cross-cultural adoption policies
George Shanti, Nico Van Oudenhoven, and Ekha Wazir, co-authors of Foster Care Beyond the Crossroads: Lessons from an International Comparative Analysis, say that there are four types of Government foster care systems. The first one is that of developing countries. These countries do not have policies implemented to take care of the basic needs of these children and these children mostly receive assistance from relatives. The second system is that of former socialist governments. The historical context of these states has not allowed for the evolution of their foster care system. NGOs have urged them to evolve; however the traditional system of institutionalizing these children is still in place. Thirdly, liberal democracies do not have the support from its political system in order to take care of these children, even though they have the resources. Finally, social democracies are the most advanced governments in regards to their foster care system. These governments have a massive infrastructure, funding, and support system in order to help foster care children.

Adoption
Foster care adoption is a type of domestic adoption where the child is initially placed into a foster care system and is subsequently placed for adoption.
Children may be placed into foster care for a variety of reasons; including, removal from the home by a governmental agency because of maltreatment. In some jurisdictions, adoptive parents are licensed as and technically considered foster parents while the adoption is being finalized. According to the U.S Department of Health and Human Services Childrens Bureau, there were approximately 408,425 children in foster care in 2010. Of those children, twenty-five percent had a goal of adoption. In 2015, 243,060 children exited foster care and twenty-two percent were adopted. Nationwide, there are more than one hundred thousand children in the U.S. foster care system waiting for permanent families.

Outcomes
Youth who are aging out of foster care often face difficulties in transitioning into adulthood, especially in terms of finding stable housing, employment, finances, and educational opportunities. The suspected reason for these difficulties involves a lack of stability experienced while in the foster care system, and the reported abuse and/or neglect in their childhood, which may affect their ability to cope with significant life changes. In the United States, there are independent living programs designed with the intent to serve the needs of transitioning foster youth. However, youth aging out of foster care have indicated that these programs are failing to fully address the needs of young adults without familial assistance.In a study conducted by Gypen et al. (2017), involving a cross-database analysis of research articles relevant to the outcomes of former foster youth, they found that the educational, mental health, employment, income, stable housing, criminal involvement and substance abuse issues outcomes for youth who have aged out of the foster care system are substantially poorer than their peers </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Intracerebral hemorrhage and explain in detail? [/INST] Intracerebral hemorrhage (ICH), also known as cerebral bleed, intraparenchymal bleed, and hemorrhagic stroke, or haemorrhagic stroke, is a sudden bleeding into the tissues of the brain, into its ventricles, or into both. It is one kind of bleeding within the skull and one kind of stroke. Symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness. Often, symptoms get worse over time. Fever is also common.Causes include brain trauma, aneurysms, arteriovenous malformations, and brain tumors. The biggest risk factors for spontaneous bleeding are high blood pressure and amyloidosis. Other risk factors include alcoholism, low cholesterol, blood thinners, and cocaine use. Diagnosis is typically by CT scan. Other conditions that may present similarly include ischemic stroke.Treatment should typically be carried out in an intensive care unit. Guidelines recommend decreasing the blood pressure to a systolic of 140 mmHg. Blood thinners should be reversed if possible and blood sugar kept in the normal range. Surgery to place a ventricular drain may be used to treat hydrocephalus, but corticosteroids should not be used. Surgery to remove the blood is useful in certain cases.Cerebral bleeding affects about 2.5 per 10,000 people each year. It occurs more often in males and older people. About 44% of those affected die within a month. A good outcome occurs in about 20% of those affected. Intracerebral hemorrhage, a type of hemorrhagic stroke, was first distinguished from ischemic strokes due to insufficient blood flow, so called "leaks and plugs", in 1823.

Signs and symptoms
People with intracerebral bleeding have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed. These localizing signs and symptoms can include hemiplegia (or weakness localized to one side of the body) and paresthesia (loss of sensation) including hemisensory loss (if localized to one side of the body). These symptoms are usually rapid in onset, sometimes occurring in minutes, but not as rapid as the symptom onset in ischemic stroke. Other symptoms include those that indicate a rise in intracranial pressure caused by a large mass (due to hematoma expansion) putting pressure on the brain. These symptoms include headaches, nausea, vomiting, a depressed level of consciousness, stupor and death. Continued elevation in the intracranial pressure and the accompanying mass effect may eventually cause brain herniation (when different parts of the brain are displaced or shifted to new areas in relation to the skull and surrounding dura mater supporting structures). Brain herniation is associated with hyperventilation, extensor rigidity, pupillary asymmetry, pyramidal signs, coma and death.Hemorrhage into the basal ganglia or thalamus causes contralateral hemiplegia due to damage to the internal capsule. Other possible symptoms include gaze palsies or hemisensory loss. Intracerebral hemorrhage into the cerebellum may cause ataxia, vertigo, incoordination of limbs and vomiting. Some cases of cerebellar hemorrhage lead to blockage of the fourth ventricle with subsequent impairment of drainage of cerebrospinal fluid from the brain. The ensuing hydrocephalus, or fluid buildup in the ventricles of the brain leads to a decreased level of consciousness and coma. Brainstem hemorrhage most commonly occurs in the pons and is associated with cranial nerve palsies, pinpoint (but reactive) pupils, gaze palsies, facial weakness, and coma (if there is damage to the reticular activating system).

Causes
Intracerebral bleeds are the second most common cause of stroke, accounting for 10% of hospital admissions for stroke. High blood pressure raises the risks of spontaneous intracerebral hemorrhage by two to six times. More common in adults than in children, intraparenchymal bleeds are usually due to penetrating head trauma, but can also be due to depressed skull fractures. Acceleration-deceleration trauma, rupture of an aneurysm or arteriovenous malformation (AVM), and bleeding within a tumor are additional causes. Amyloid angiopathy is not an uncommon cause of intracerebral hemorrhage in patients over the age of 55. A very small proportion is due to cerebral venous sinus thrombosis.Risk factors for ICH include:
Hypertension (high blood pressure)
Diabetes mellitus
Menopause
Excessive alcohol consumption
Severe migraineHypertension is the strongest risk factor associated with intracerebral hemorrhage and long term control of elevated blood pressure has been shown to reduce the incidence of hemorrhage. Cerebral amyloid angiopathy, a disease characterized by deposition of amyloid beta peptides in the walls of the small blood vessels of the brain, leading to weakened blood vessel walls and an increased risk of bleeding; is also an important risk factor for the development of intracerebral hemorrhage. Other risk factors include advancing age (usually with a concomitant increase of cerebral amyloid angiopathy risk in the elderly), use of anticoagulants or antiplatelet medications, the presence of cerebral microbleeds, chronic kidney disease, and low low density lipoprotein (LDL) levels (usually below 70). The direct oral anticoagulants (DOACs) such as the factor Xa inhibitors or direct thrombin inhibitors are thought to have a lower risk of intracerebral hemorrhage as compared to the vitamin K antagonists such as warfarin.Cigarette smoking may be a risk factor but the association is weak.Traumautic intracerebral hematomas are divided into acute and delayed. Acute intracerebral hematomas occur at the time of the injury while delayed intracerebral hematomas have been reported from as early as 6 hours post injury to as long as several weeks.

Diagnosis
Both computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been proved to be effective in diagnosing intracranial vascular malformations after ICH. So frequently, a CT angiogram will be performed in order to exclude a secondary cause of hemorrhage or to detect a "spot sign".
Intraparenchymal hemorrhage can be recognized on CT scans because blood appears brighter than other tissue and is separated from the inner table of the skull by brain tissue. The tissue surrounding a bleed is often less dense than the rest of the brain because of edema, and therefore shows up darker on the CT scan. The oedema surrounding the haemorrhage would rapidly increase in size in the first 48 hours, and reached its maximum extent at day 14. The bigger the size of the haematoma, the larger its surrounding oedema.

Location
When due to high blood pressure, intracerebral hemorrhages typically occur in the putamen (50%) or thalamus (15%), cerebrum (10–20%), cerebellum (10–13%), pons (7–15%), or elsewhere in the brainstem (1–6%).

Treatment
Treatment depends substantially on the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery.

Tracheal intubation is indicated in people with decreased level of consciousness or other risk of airway obstruction.
IV fluids are given to maintain fluid balance, using isotonic rather than hypotonic fluids.Rapid lowering of the blood pressure for those with hypertensive emergency can have higher functional recovery at 90 days post intracerebral haemorrhage, when compared to those who undergone other treatments such as mannitol administration, reversal of anticoagulation (those previously on anticoagulant treatment for other conditions), surgery to evacuate the haematoma, and standard rehabilitation care in hospital, while showing similar rate of death at 12%.

Medication
One review found that antihypertensive therapy to bring down the blood pressure in acute phases appears to improve outcomes. Other reviews found an unclear difference between intensive and less intensive blood pressure control. The American Heart Association and American Stroke Association guidelines in 2015 recommended decreasing the blood pressure to a SBP of 140 mmHg. However, the evidence finds tentative usefulness as of 2015.
Giving Factor VIIa within 4 hours limits the bleeding and formation of a hematoma. However, it also increases the risk of thromboembolism. It thus overall does not result in better outcomes in those without hemophilia.
Frozen plasma, vitamin K, protamine, or platelet transfusions may be given in case of a coagulopathy. Platelets however appear to worsen outcomes in those with spontaneous intracerebral bleeding on antiplatelet medication.
The specific reversal agents idarucizumab and andexanet alfa may be used to stop continued intracerebral hemorrhage in people taking directly oral acting anticoagulants (such as factor Xa inhibitors or direct thrombin inhibitors). However, if these specialized medications are not available, prothrombin complex concentrate may also be used.
Fosphenytoin or other anticonvulsant is given in case of seizures or lobar hemorrhage.
H2 antagonists or proton pump inhibitors are commonly given for to try to prevent stress ulcers, a condition linked with ICH.
Corticosteroids, were thought to reduce swelling. However, in large controlled studies, corticosteroids have been found to increase mortality rates and are no longer recommended.

Surgery
Surgery is required if the hematoma is greater than 3 cm (1 in), if there is a structural vascular lesion or lobar hemorrhage in a young patient.
A catheter may be passed into the brain vasculature to close off or dilate blood vessels, avoiding invasive surgical procedures.
Aspiration by stereotactic surgery or endoscopic drainage may be used in basal ganglia hemorrhages, although successful reports are limited.
A craniectomy holds promise of reduced mortality, but the effects of long‐term neurological outcome remain controversial.

Prognosis
The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high when the injury occurs in the brain stem. Intraparenchymal bleeds within the medulla oblongata are almost always fatal, because they cause damage to cranial nerve X, the vagus nerve, which plays an important role in blood circulation and breathing. This kind of hemorrhage can also occur in the cortex or subcortical areas, usually in the frontal or temporal lobes when due to head injury, and sometimes in the cerebellum. Larger volumes of hematoma at hospital admission as well as greater expansion of the hematoma on subsequent evaluation (usually occurring within 6 hours of symptom onset) are associated with a worse prognosis. Perihematomal edema, or secondary edema surrounding the hematoma, is associated with secondary brain injury, worsening neurological function and is associated with poor outcomes. Intraventricular hemorrhage, or bleeding into the ventricles of the brain, which may occur in 30-50% of patients, is also associated with long term disability and a poor prognosis. Brain herniation is associated with poor prognoses.For spontaneous intracerebral hemorrhage seen on CT scan, the death rate (mortality) is 34–50% by 30 days after the injury, and half of the deaths occur in the first 2 days. Even though the majority of deaths occur in the first few days after ICH, survivors have a long-term excess mortality rate of 27% compared to the general population. Of those who survive an intracerebral hemorrhage, 12–39% are independent with regard to self-care; others are disabled to varying degrees and require supportive care.

Epidemiology
The incidence of intracerebral hemorrhage is estimated at 24.6 cases per 100,000 person years with the incidence rate being similar in men and women. The incidence is much higher in the elderly, especially those who are 85 or older, who are 9.6 times more likely to have an intracerebral hemorrhage as compared to those of middle age. It accounts for 20% of all cases of cerebrovascular disease in the United States, behind cerebral thrombosis (40%) and cerebral embolism (30%).

History
Intracerebral hemorrhage was first distinguished from strokes due to insufficient blood flow, so called "leaks and plugs", in 1823 </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Legionnaires disease and explain in detail? [/INST] Legionnaires disease is a form of atypical pneumonia caused by any species of Legionella bacteria, quite often Legionella pneumophila. Signs and symptoms include cough, shortness of breath, high fever, muscle pains, and headaches. Nausea, vomiting, and diarrhea may also occur. This often begins 2–10 days after exposure.A legionellosis is any disease caused by Legionella, including Legionnaires disease (a pneumonia), Pontiac fever (a nonpneumonia illness), and Pittsburgh pneumonia, but Legionnaires disease is the most common, so mentions of legionellosis often refer to Legionnaires disease.
The bacterium is found naturally in fresh water. It can contaminate hot water tanks, hot tubs, and cooling towers of large air conditioners. It is usually spread by breathing in mist that contains the bacteria. It can also occur when contaminated water is aspirated. It typically does not spread directly between people, and most people who are exposed do not become infected. Risk factors for infection include older age, a history of smoking, chronic lung disease, and poor immune function. Those with severe pneumonia and those with pneumonia and a recent travel history should be tested for the disease. Diagnosis is by a urinary antigen test and sputum culture.No vaccine is available. Prevention depends on good maintenance of water systems. Treatment of Legionnaires disease is with antibiotics. Recommended agents include fluoroquinolones, azithromycin, or doxycycline. Hospitalization is often required. The fatality rate is around 10% for healthy persons and 25% for those with underlying conditions.The number of cases that occur globally is not known.  Legionnaires disease is the cause of an estimated 2–9% of pneumonia cases that are acquired outside of a hospital. An estimated 8,000 to 18,000 cases a year in the United States require hospitalization. Outbreaks of disease account for a minority of cases. While it can occur any time of the year, it is more common in the summer and fall. The disease is named after the outbreak where it was first identified, at a 1976 American Legion convention in Philadelphia.

Signs and symptoms
The length of time between exposure to the bacteria and the appearance of symptoms (incubation period) is generally 2–10 days, but can more rarely extend to as long as 20 days. For the general population, among those exposed, between 0.1 and 5.0% develop the disease, while among those in hospital, between 0.4 and 14% develop the disease.Those with Legionnaires disease usually have fever, chills, and a cough, which may be dry or may produce sputum. Almost all experience fever, while around half have cough with sputum, and one-third cough up blood or bloody sputum. Some also have muscle aches, headache, tiredness, loss of appetite, loss of coordination (ataxia), chest pain, or diarrhea and vomiting. Up to half of those with Legionnaires disease have gastrointestinal symptoms, and almost half have neurological symptoms, including confusion and impaired cognition. "Relative bradycardia" may also be present, which is low to normal heart rate despite the presence of a fever.Laboratory tests may show that kidney functions, liver functions, and electrolyte levels are abnormal, which may include low sodium in the blood. Chest X-rays often show pneumonia with consolidation in the bottom portion of both lungs. Distinguishing Legionnaires disease from other types of pneumonia by symptoms or radiologic findings alone is difficult; other tests are required for definitive diagnosis.People with Pontiac fever, a much milder illness caused by the same bacterium, experience fever and muscle aches without pneumonia. They generally recover in 2–5 days without treatment. For Pontiac fever, the time between exposure and symptoms is generally a few hours to two days.

Cause
Over 90% of cases of Legionnaires disease are caused by Legionella pneumophila. Other types include L. longbeachae, L. feeleii, L. micdadei, and L. anisa.

Transmission
Legionnaires disease is usually spread by the breathing in of aerosolized water or soil contaminated with the Legionella bacteria. Experts have stated that Legionnaires disease is not transmitted from person to person. In 2014, one case of possible spread from someone sick to the caregiver occurred. Rarely, it has been transmitted by direct contact between contaminated water and surgical wounds. The bacteria grow best at warm temperatures and thrive at water temperatures between 25 and 45 °C (77 and 113 °F), with an optimum temperature of 35 °C (95 °F). Temperatures above 60 °C (140 °F) kill the bacteria. Sources where temperatures allow the bacteria to thrive include hot water tanks, cooling towers, and evaporative condensers of large air conditioning systems, such as those commonly found in hotels and large office buildings. Though the first known outbreak was in Philadelphia, cases of legionellosis have occurred throughout the world.

Reservoirs
L. pneumophila thrives in aquatic systems, where it is established within amoebae in a symbiotic relationship. Legionella bacteria survive in water as intracellular parasites of water-dwelling protozoa, such as amoebae. Amoebae are often part of biofilms, and once Legionella and infected amoebae are protected within a biofilm, they are particularly difficult to destroy.In the built environment, central air conditioning systems in office buildings, hotels, and hospitals are sources of contaminated water. Other places the bacteria can dwell include cooling towers used in industrial cooling systems, evaporative coolers, nebulizers, humidifiers, whirlpool spas, hot water systems, showers, windshield washers, fountains, room-air humidifiers, ice-making machines, and misting systems typically found in grocery-store produce sections.The bacteria may also be transmitted from contaminated aerosols generated in hot tubs if the disinfection and maintenance programs are not followed rigorously. Freshwater ponds, creeks, and ornamental fountains are potential sources of Legionella. The disease is particularly associated with hotels, fountains, cruise ships, and hospitals with complex potable water systems and cooling systems. Respiratory-care devices such as humidifiers and nebulizers used with contaminated tap water may contain Legionella species, so using sterile water is very important. Other sources include exposure to potting mix and compost.

Mechanism
Legionella spp. enter the lungs either by aspiration of contaminated water or inhalation of aerosolized contaminated water or soil. In the lung, the bacteria are consumed by macrophages, a type of white blood cell, inside of which the Legionella bacteria multiply, causing the death of the macrophage. Once the macrophage dies, the bacteria are released from the dead cell to infect other macrophages. Virulent strains of Legionella kill macrophages by blocking the fusion of phagosomes with lysosomes inside the host cell; normally, the bacteria are contained inside the phagosome, which merges with a lysosome, allowing enzymes and other chemicals to break down the invading bacteria.

Diagnosis
People of any age may develop Legionnaires disease, but the illness most often affects middle-aged and older people, particularly those who smoke cigarettes or have chronic lung disease. Immunocompromised people are also at higher risk. Pontiac fever most commonly occurs in those who are otherwise healthy.The most useful diagnostic tests detect the bacteria in coughed-up mucus, find Legionella antigens in urine samples, or allow comparison of Legionella antibody levels in two blood samples taken 3–6 weeks apart. A urine antigen test is simple, quick, and very reliable, but only detects L. pneumophila serogroup 1, which accounts for 70% of disease caused by L. pneumophila, which means use of the urine antigen test alone may miss as many as 30% of cases. This test was developed by Richard Kohler in 1982. When dealing with L. pneumophila serogroup 1, the urine antigen test is useful for early detection of Legionnaires disease and initiation of treatment, and has been helpful in early detection of outbreaks. However, it does not identify the specific subtypes, so it cannot be used to match the person with the environmental source of infection. The Legionella bacteria can be cultured from sputum or other respiratory samples. Legionella spp. stain poorly with Gram stain, stain positive with silver, and are cultured on charcoal yeast extract with iron and cysteine (CYE agar).
A significant under-reporting problem occurs with legionellosis. Even in countries with effective health services and readily available diagnostic testing, about 90% of cases of Legionnaires disease are missed. This is partly due to the disease being a relatively rare form of pneumonia, which many clinicians may not have encountered before, thus may misdiagnose. A further issue is that people with legionellosis can present with a wide range of symptoms, some of which (such as diarrhea) may distract clinicians from making a correct diagnosis.

Prevention
Although the risk of Legionnaires disease being spread by large-scale water systems cannot be eliminated, it can be greatly reduced by writing and enforcing a highly detailed, systematic water safety plan appropriate for the specific  facility involved (office building, hospital, hotel, spa, cruise ship, etc.) Some of the elements that such a plan may include are:

Keep water temperature either above or below the 20–50 °C (68–122 °F) range in which the Legionella bacterium thrives.
Prevent stagnation, for example, by removing from a network of pipes any sections that have no outlet (dead ends). Where stagnation is unavoidable, as when a wing of a hotel is closed for the off-season, systems must be thoroughly disinfected just prior to resuming normal operation.
Prevent the buildup of biofilm, for example, by not using (or by replacing) construction materials that encourage its development, and by reducing the quantity of nutrients for bacterial growth that enter the system.
Periodically disinfect the system, by high heat or a chemical biocide, and use chlorination where appropriate. Treatment of water with copper-silver ionization or ultraviolet light may also be effective.
System design (or renovation) can reduce the production of aerosols and reduce human exposure to them, by directing them well away from building air intakes.An effective water safety plan also covers such matters as training, record-keeping, communication among staff, contingency plans, and management responsibilities. The format and content of the plan may be prescribed by public health laws or regulations. To inform the water safety plan, the undertaking of a site specific legionella risk assessment is often recommended in the first instance. The legionella risk assessment identifies the hazards, the level of risk they pose and provides recommendations of control measures to put place within the overarching water safety plan.

Treatment
Effective antibiotics include most macrolides, tetracyclines, ketolides, and quinolones. Legionella spp. multiply within the cell, so any effective treatment must have excellent intracellular penetration. Current treatments of choice are the respiratory tract quinolones (levofloxacin, moxifloxacin, gemifloxacin) or newer macrolides (azithromycin, clarithromycin, roxithromycin). The antibiotics used most frequently have been levofloxacin, doxycycline, and azithromycin.
Macrolides (azithromycin) are used in all age groups, while tetracyclines (doxycycline) are prescribed for children above the age of 12 and quinolones (levofloxacin) above the age of 18. Rifampicin can be used in combination with a quinolone or macrolide. Whether rifampicin is an effective antibiotic to take for treatment is uncertain. The Infectious Diseases Society of America does not recommend the use of rifampicin with added regimens. Tetracyclines and erythromycin led to improved outcomes compared to other antibiotics in the original American Legion outbreak. These antibiotics are effective because they have excellent intracellular penetration in Legionella-infected cells. The recommended treatment is 5–10 days of levofloxacin or 3–5 days of azithromycin, but in people who are immunocompromised, have severe disease, or other pre-existing health conditions, longer antibiotic use may be necessary. During outbreaks, prophylactic antibiotics have been used to prevent Legionnaires disease in high-risk individuals who have possibly been exposed.The mortality at the original American Legion convention in 1976 was high (29 deaths in 182 infected individuals) because the antibiotics used (including penicillins, cephalosporins, and aminoglycosides) had poor intracellular penetration. Mortality has plunged to less than 5% if therapy is started quickly. Delay in giving the appropriate antibiotic leads to higher mortality.

Prognosis
The fatality rate of Legionnaires disease has ranged from 5–30% during various outbreaks and approaches 50% for nosocomial infections, especially when treatment with antibiotics is delayed. Hospital-acquired Legionella pneumonia has a fatality rate of 28%, and the principal source of infection in such cases is the drinking-water distribution system.

Epidemiology
Legionnaires disease acquired its name in July 1976, when an outbreak of pneumonia occurred among people attending a convention of the American Legion at the Bellevue-Stratford Hotel in Philadelphia. Of the 182 reported cases, mostly men, 29 died. On 18 January 1977, the causative agent was identified as a previously unknown strain of bacteria, subsequently named Legionella, and the species that caused the outbreak was named Legionella pneumophila. Following this discovery, unexplained outbreaks of severe respiratory disease from the 1950s were retrospectively attributed to Legionella. Legionnaires disease also became a prominent historical example of an emerging infectious disease.Outbreaks of Legionnaires disease receive significant media attention, but this disease usually occurs in single, isolated cases not associated with any recognized outbreak. When outbreaks do occur, they are usually in the summer and early autumn, though cases may occur at any time of year. Most infections occur in those who are middle-aged or older. National surveillance systems and research studies were established early, and in recent years, improved ascertainment and changes in clinical methods of diagnosis have contributed to an upsurge in reported cases in many countries. Environmental studies continue to identify novel sources of infection, leading to regular revisions of guidelines and regulations. About 8,000 to 18,000 cases of Legionnaires disease occur each year in the United States, according to the Bureau of Communicable Disease Control.Between 1995 and 2005, over 32,000 cases of Legionnaires disease and more than 600 outbreaks were reported to the European Working Group for Legionella Infections. The data on Legionella are limited in developing countries, and Legionella-related illnesses likely are underdiagnosed worldwide. Improvements in diagnosis and surveillance in developing countries would be expected to reveal far higher levels of morbidity and mortality than are currently recognised. Similarly, improved diagnosis of human illness related to Legionella species and serogroups other than Legionella pneumophila would improve knowledge about their incidence and spread.A 2011 study successfully used modeling to predict the likely number of cases during Legionnaires outbreaks based on symptom onset dates from past outbreaks. In this way, the eventual likely size of an outbreak can be predicted, enabling efficient and effective use of public-health resources in managing an outbreak.During the COVID-19 pandemic, some researchers and organisations raised concerns about the impact of the COVID-19 lockdowns on Legionnaires disease outbreaks. Additionally, at least two people in England died from a co-infection of Legionella and SARS-CoV-2.

Outbreaks
An outbreak is defined as two or more cases where the onset of illness is closely linked in time (weeks rather than months) and space, where a suspicion  or evidence exists of a common source of infection, with or without microbiological support (i.e. common spatial location of cases from travel history).In April 1985, 175 people in Stafford, England, were admitted to the District or Kingsmead Stafford Hospitals with chest infection or pneumonia. A total of 28 people died. Medical diagnosis showed that Legionnaires disease was responsible and the immediate epidemiological investigation traced the source of the infection to the air-conditioning cooling tower on the roof of Stafford District Hospital.In March 1999, a large outbreak in the Netherlands occurred during the Westfriese Flora flower exhibition in Bovenkarspel; 318 people became ill and at least 32 people died. This was the second-deadliest outbreak since the 1976 outbreak and possibly the deadliest, as several people were buried before Legionnaires disease had been diagnosed.The worlds largest outbreak of Legionnaires disease happened in July 2001, with people appearing at the hospital on 7 July, in Murcia, Spain. More than 800 suspected cases were recorded by the time the last case was treated on 22 July; 636–696 of these cases were estimated and 449 confirmed (so, at least 16,000 people were exposed to the bacterium) and six died, a case-fatality rate around 1%.In September 2005, 127 residents of a nursing home in Canada became ill with L. pneumophila. Within a week, 21 of the residents had died. Culture results at first were negative, which is not unusual, as L. pneumophila is a "fastidious" bacterium, meaning it requires specific nutrients, living conditions, or both to grow. The source of the outbreak was traced to the air-conditioning cooling towers on the nursing homes roof.In an outbreak in lower Quebec City, Canada, 180 people were affected with 13 resulting deaths  due to contaminated water in a cooling tower.In November 2014, 302 people were hospitalized following an outbreak of legionellosis in Portugal, and seven related deaths were reported. All cases emerged in three civil parishes from the municipality of Vila Franca de Xira in the northern outskirts of Lisbon, and were treated in hospitals of the greater Lisbon area. The source is suspected to be located in the cooling towers of the fertilizer plant Fertibéria.Twelve people were diagnosed with the disease in an outbreak in the Bronx, New York, in December 2014; the source was traced to contaminated cooling towers at a housing development. In July and August 2015, another, unrelated outbreak in the Bronx killed 12 people and made about 120 people sick; the cases arose from a cooling tower on top of a hotel. At the end of September, another person died of the disease and 13 were sickened in yet another unrelated outbreak in the Bronx.  The cooling towers from which the people were infected in the latter outbreak had been cleaned during the summer outbreak, raising concerns about how well the bacteria could be controlled.On 28 August 2015, an outbreak of Legionnaires disease was detected at San Quentin State Prison in Northern California; 81 people were sickened and the cause was sludge that had built up in cooling towers.Between June 2015, and January 2016, 87 cases of Legionnaires disease were reported by the Michigan Department of Health and Human Services for the city of Flint, Michigan, and surrounding areas. The outbreak may have been linked to the Flint water crisis, in which the citys water source was changed to a cheaper and inadequately treated source. Ten of those cases were fatal.In November 2017, an outbreak was detected at Hospital de São Francisco Xavier, Lisbon, Portugal, with up to 53 people being diagnosed with the disease and five of them dying from it.In Quincy, Illinois, at the Illinois Veterans Home, a 2015 outbreak of the disease killed 12 people and sickened more than 50 others </s>


<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, please don't share false information. <</SYS>> What is Kernicterus and explain in detail? [/INST] Kernicterus is a bilirubin-induced brain dysfunction. The term was coined in 1904 by Christian Georg Schmorl.  Bilirubin is a naturally occurring substance in the body of humans and many other animals, but it is neurotoxic when its concentration in the blood is too high, a condition known as hyperbilirubinemia. Hyperbilirubinemia may cause bilirubin to accumulate in the grey matter of the central nervous system, potentially causing irreversible neurological damage. Depending on the level of exposure, the effects range from clinically unnoticeable to severe brain damage and even death.
When hyperbilirubinemia increases past a mild level, it leads to jaundice, raising the risk of progressing to kernicterus. When this happens in adults, it is usually because of liver problems.  Newborns are especially vulnerable to hyperbilirubinemia-induced neurological damage, because in the earliest days of life, the still-developing liver is heavily exercised by the breakdown of fetal hemoglobin as it is replaced with adult hemoglobin and the blood–brain barrier is not as developed. Mildly elevated serum bilirubin levels are common in newborns, and neonatal jaundice is not unusual, but bilirubin levels must be carefully monitored in case they start to climb, in which case more aggressive therapy is needed, usually via light therapy but sometimes even via exchange transfusion.

Classification
Acute bilirubin encephalopathy (ABE)
ABE is an acute state of elevated bilirubin in the central nervous system. Clinically, it encompasses a wide range of symptoms. These include lethargy, decreased feeding, hypotonia or hypertonia, a high-pitched cry, spasmodic torticollis, opisthotonus, setting sun sign, fever, seizures, and even death. If the bilirubin is not rapidly reduced, ABE quickly progresses to chronic bilirubin encephalopathy.

Chronic bilirubin encephalopathy (CBE)
CBE is a chronic state of severe bilirubin-induced neurological lesions. Reduction of bilirubin in this state will not reverse the sequelae. Clinically, manifestations of CBE include:
movement disorders – dyskinetic CP with often spasticity.  60% have severe motor disability (unable to walk).
auditory dysfunction – auditory neuropathy (ANSD)
visual/oculomotor impairments (nystagmus, strabismus, impaired upward or downward gaze, and/or cortical visual impairment). In rare cases, decreased visual acuity(blindness) can occur.
dental enamel hypoplasia/dysplasia of the deciduous teeth,
gastroesophageal reflux,
impaired digestive function.
slightly decreased intellectual function: Although most individuals (approximately 85%) with kernicterus fall in normal or dull-normal range.
epilepsy is uncommon.These impairments are associated with lesions in the basal ganglia, auditory nuclei of the brain stem, and oculomotor nuclei of the brain stem. Cortex and white matter are subtly involved. Cerebellum may be involved. Severe cortical involvement is uncommon.

Subtle bilirubin encephalopathy (SBE)
SBE is a chronic state of mild bilirubin-induced neurological dysfunction (BIND). Clinically, this may result in neurological, learning and movement disorders, isolated hearing loss and auditory dysfunction.
In the past it was thought that kernicterus (KI) often cause an intellectual disability.  This was assumed due to difficulty with hearing, that is typically not detected in a normal audiogram accompanied by impairments of speech, with choreoathetosis. With advances in technology, this has proven to not be the case as those living with KI have repeatedly demonstrated their intelligence using Augmentative Communication devices. Although most individuals with kernicteric cerebral palsy have normal intelligence, some children with mild choreoathetosis develop dull normal intelligence or mild intellectual disability even without auditory dysfunction.

Causes
In the vast majority of cases, kernicterus is associated with unconjugated hyperbilirubinemia during the neonatal period. The blood–brain barrier is not fully functional in neonates and therefore bilirubin is able to cross into the central nervous system. Moreover, neonates have much higher levels of bilirubin in their blood due to:

Rapid breakdown of fetal red blood cells immediately prior to birth, with subsequent replacement by normal adult human red blood cells. This breakdown of fetal red blood cells releases large amounts of bilirubin.
Severe hemolytic disease of the newborn. Many children who survive exhibit permanent mental impairment or damage to motor areas of the brain because of precipitation of bilirubin in neurons.
Neonates have a limited ability to metabolize and excrete bilirubin. The sole pathway for bilirubin elimination is through the uridine diphosphate glucuronosyltransferase isoform 1A1 (UGT1A1) enzyme, which performs a reaction called "glucuronidation". This reaction adds a large sugar to the bilirubin, which makes the compound more water-soluble, so it can be more readily excreted via the urine and/or the feces. The UGT1A1 enzyme is not active in appreciable amounts until several months after birth. Apparently, this is a developmental compromise since the maternal liver and placenta perform glucuronidation for the fetus.
Administration of aspirin to neonates and infants. Aspirin displaces bilirubin from serum albumin, thus generating an increased level of free bilirubin which can cross the developing blood brain barrier. This can be life-threatening.Bilirubin is known to accumulate in the gray matter of neurological tissue where it exerts direct neurotoxic effects </s>