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In philosopher Martin Buber's classic work I and Thou, he suggests that in authentic dialogue something far deeper than ordinary conversation is going on. The I-Thou interaction implies a genuine openness of each individual to the concerns of the other. In such dialogue, "I" do not, while talking with you, selectively tune out views I disagree with, nor do I busy myself marshaling arguments to rebut you while only half attending to what you have to say. Nor do I seek to reinforce my own prejudices. Instead, I fully take in your viewpoint, engaging with it in the deepest sense of the term. You do likewise. Each of us internalizes the view of the other to enhance our mutual understanding.

Buber voiced the stunning insight that, apart from its obvious practical value for problem-solving, dialogue expresses an essential aspect of the human spirit. He knew that dialogue is a way of being. In Buber's philosophy, life itself is a form of meeting, and dialogue is the place where we meet. In dialogue, we penetrate behind the polite superficialities and defenses in which we habitually armor ourselves. We listen and respond to one another with a kind of authenticity that forges a bond between us.

By performing the seemingly simple act of responding empathetically to others and in turn being heard by them, Buber observed, we transcend the constricting confines of the self. Instead of saying, "you or me," you hear yourself saying, "you and me." The act of reaching beyond the self to relate to others in dialogue is a profound human yearning. If it were less commonplace we would realize what a miracle it is.

Missing Skills

If the yearning for dialogue is universal, why is it so rare? Because it calls upon skills that impose a rigorous discipline on participants. Most people have not taken the time and effort to develop these skills. The reason is not lack of motivation. People have ample incentive to acquire the skills of dialogue. They have not done so for several reasons:

• Models are lacking. Television, for example, resorts to the conflicting debate format when presenting politics and other serious subjects because of its entertainment value.
• The skills of dialogue have not been clearly identified, so people who wish to acquire them do not know what they are.
• There are no obvious consequences of failure to develop the skills. If you tried to swim or ski without knowing how, your lack of skill would be swiftly and dramatically obvious, perhaps fatally so. If you fail at dialogue, it is not at all obvious that the reason is lack of dialogic skill, or even that a failure has occurred.

Significantly, success at dialogue is much more self-evident than failure. When dialogue is done well, the results can be extraordinary: Long-standing stereotypes dissolved, mistrust overcome, mutual understanding achieved, visions shaped and grounded in shared purpose, people previously at odds with one another aligned on objectives and strategies, new common ground discovered, new perspective and insights gained, new levels of creativity stimulated, and bonds of communication strengthened.

I do not want to overstate the benefits of dialogue. Though I believe it sometimes has almost magical properties, it is not a panacea for all the problems that ail us. Faith in the ability to talk to solve problems is very American, and to some cynics, a sign of our cultural na?vet?. It's easy to poke fun at serious, well-meaning attempts at dialogue that miscarry, as many unfortunately do.

As our society becomes increasingly fragmented and pluralistic, we're likely to misunderstand one another more and more. Ordinary discussion is not powerful enough to break through these misunderstandings. We will need increasingly to resort to the more potent resources of dialogue. All of us will need to know how to initiate and carry out spontaneous dialogue.

Constant readiness is the key to success. You never know when an opportunity for spontaneous dialogue will arise. If you are not ready to take advantage of it, the opportunity will pass you by. Worse yet, you may get drawn into a dialogue that will turn sour, leaving the bad taste of failure.

Constant readiness means that you know the strategies for doing dialogue successfully, and feel comfortable in applying the most important ones. (See "Strategies for Successful Dialogue" on the next page) For example, you understand the core requirements for dialogue ? treating the other as an equal in every respect (part of what Buber meant by "thou"), being willing and able to bring everyone's assumptions ? including yours ? into the open without becoming judgmental.

Should the need arise you must be psychologically prepared to perform an act of empathy ? which requires both self-confidence and the lowering of defenses. If you are in full battle gear, as many of us are these days in our encounters with a self-absorbed world, it is easy to interpret an act of empathy as a loss of face, a deficit of macho. I suspect that most opportunities to initiate dialogue are lost because participants are not psychologically prepared to take this first critical step.

You must also be prepared to confront misunderstandings through focusing on assumptions ? both your own and others. Misunderstandings arise from many sources ? from friction between subcultures to differences in interests. The most complex of all are transference-driven distortions. When you misunderstand people from other subcultures, you may be transferring to them attributes, feelings, and beliefs that are part of your own subculture. When you misunderstand people from within your own subculture, you may be transferring to them interests and feelings more appropriate to the ghosts of your past than to them.

Test Yourself

Are you ready for dialogue? Test yourself by asking yourself some searching questions. Suppose, for example, you are an executive in a meeting attended by people of varied ranks within your organization ? some who report to you, others who hold a higher position. A discussion is in progress regarding a project that did not work out according to plan. Lots of criticism is being bandied about. Are you prepared to volunteer that you accept some responsibility because of erroneous assumptions you had made, and then to make them explicit? If not, you may want to do more to prepare yourself for dialogue.

Or suppose you are a married man and you have just had a quarrel with your wife. You tell a friend, who then asks you, "After your quarrel, did your wife feel you had listened fully and sympathetically to her side of the story?" If your answer is "no" or "I'm not sure," the chances are you are not quite ready to enter into dialogue with your wife.

Or suppose you are a woman with a younger sister whom you habitually treat as not quite equal to you in experience or smarts. Ask yourself if your attitude toward her reflects the person she is today, or whether you are still reacting to her as she was in the past. To prepare yourself for dialogue with her, you may want to divest yourself of some of the baggage of the past.

One should not underestimate how difficult it is to break ingrained habits of not-listening, to break out of your wall of guarded reserve in order to offer acts of empathy, or to develop the skill of digging out your own and other people's transferences in a non-judgmental fashion. But I'm convinced that everyone can learn to do dialogue, and that each one who does gives a gift to us all.

Strategies for Successful Dialogue

The following is a checklist of strategies for successful dialogue. Yankelovich's book, The Magic of Dialogue, explains each one in detail.

• Check for the presence of all three core requirements of dialogue ? equality, empathy, and openness ? and learn how to introduce missing ones. This is the bedrock strategy; without it you do not have dialogue.
• Focus on common interests, not the divisive ones.
• Keep dialogue and decision-making separate and compartmentalized.
• Clarify assumptions that lead to subculture distortions.
• Offer your own assumptions before speculating on those of others.
• Use specific cases to raise general issues.
• Focus on conflicts between value systems, not persons.
• When appropriate, express the emotions that accompany strongly held values.
• Initiate dialogue through an act of empathy.
• Be sure trust exists before addressing transference distortions.
• Where applicable, identify mistrust as the real source of misunderstandings.
• Err on the side of including people who disagree.
• Encourage relationships in order to humanize transactions.
• Expose old scripts to a reality check.
• Minimize the level of mistrust before pursuing practical objectives. Daniel Yankelovich is the author of The Magic of Dialogue. This article first appeared in Spirituality and Health.Head Start Bulletin
  Issue No. 68
  Page last modified or reviewed on January 24, 2014

Child sexual abuse; it is not a topic that makes people comfortable. Discussing child sexual abuse, in fact, remains taboo even in this era of increasing openness about personal or family difficulties. While most Americans can understand, although not condone, how some forms of child abuse occur, it is almost impossible for them to consider the idea of sexual abuse. This is particularly true when the abuser is a parent or family member.

Sexual abuse fuses those areas in which most people still experience discomfort: sexuality, power, gender domination, and the horrific exploitation of an innocent child. Sexual molestation, like so many forms of abuse, wounds not only its victim: it cuts through families and communities, destroying trust and the belief that some things simply do not happen in an enlightened society.

And yet they do. Almost 1 million children were identified as victims of substantiated or indicated abuse or neglect in 1996, according to the Office of Child Abuse and Neglect (formerly the National Center on Child Abuse and Neglect), U.S. Department of Health and Human Services (DHHS). About 12 percent of these children were sexually abused. The figures, of course, include only those incidents of abuse that were reported to, and investigated by, child protection agencies.

Despite these numbers, the Nation lives in denial. The results of this country's refusal to confront the sexual molestation of children are staggering. These include gaps in services to young survivors, little research into the effects of sexual abuse, inadequate technical assistance on effective approaches to supporting youth who have been sexually abused or intervening with their families, and few therapists trained to provide appropriate services. The limited intervention and support typically given to youth survivors is compounded by the fact that they must deal with their trauma in a society that is reluctant to acknowledge that child sexual abuse even occurs.

Denial is a costly tactic:

• The research shows that victims often become victimizers.
• Victims seek comfort in behaviors, such as alcohol or drug abuse, that have consequences for the larger community.
• Severely wounded children sometimes grow up to be violently aggressive adults.

Moreover, a Nation is judged by how it cares for its most vulnerable populations, and to ignore the victimization of children is unacceptable.

Talking About the Unthinkable

Twenty years ago, no one wanted to admit that men beat their wives. Domestic violence was unthinkable, especially in affluent neighborhoods. Today, people know that domestic violence occurs in families across the spectrum of racial groups, and education and income levels. Society's perception of, and response to, domestic violence was changed by battered women's advocates who continued to talk about violence in the home, even when those around them wished they would stop.

Today, that education process must continue. Violence in the home includes sexual violence. And just as with domestic violence, the effects are intergenerational. Clearly, preventing the sexual abuse of future generations by treating the victims of today should be a priority. A key strategy for doing so is to implement a youth development approach that ensures services and opportunities for all youth, that builds on young people's strengths, and that provides support for youth whose developmental process has been delayed by abuse and neglect. Young people who have been sexually abused, especially by a trusted adult, suffer damage to almost every aspect of their personal development: sexual, physical, emotional, and spiritual.

Child Sexual Abuse: The Impact on Adolescent Development

Our culture demands that children mature from an egocentric to a sociocentric focus. They are expected to participate in school, become involved in the community, and develop relationships outside their families. This is a challenging process even for the average young person; living with abuse makes the process incredibly difficult. During adolescence, youth are growing and changing in a range of ways that are affected by sexual abuse:

• Physiological Change: How tall they are or how much they weigh becomes a source of concern to young people during adolescence, particularly as they compare themselves with their peers. That comparison may produce feelings of anxiety or contribute to dampening their self-esteem. For youth who have experienced abuse or criticism by their parents, teasing about their looks may reinforce their perception that they are not valued.
• Emotional Development: Young people in abusive situations must redirect their energy from emotional development to survival. When they are forced to focus on avoiding the violent or sexual advances of an adult caretaker, they do not make the same developmental progress as children who receive unconditional love, support, and guidance.
• Cognitive Change: Young people develop their cognitive thinking ability, which means that they will reexperience and reframe abuse that occurred to them earlier, particularly if it began when they were young.
• Moral and Spiritual Development: During adolescence, youth begin to question the meaning of life and specifically to think about the larger world, the role they play in it, and the options and opportunities available to them.
• Sexual Development: For some young people, it is during adolescence that the real consequences of being sexually abused occur. When a child of 3 or 4 years of age is sexually abused, it is not a sexual event in the way adults may think. It is physically hurtful, confusing, and alarming, but they do not have a context for defining the abuse. When those children turn 12 or 13, they cognitively reassess the abuse as they begin to learn about or experience sexual feelings.

While all young people's development is affected by both internal and external factors, each youth experiences growing up differently. For youth who are abused, however, that process is negatively affected, resulting in certain reactions or behaviors.

The Abused Adolescent

While there is no clear profile of a sexually abused child, the research indicates that there are symptoms that present frequently in young survivors. These include the following:

• Anxiety/Numbing: Young people who have been sexually abused often exhibit the polarity of anxiety/numbing behaviors. These youth are hypervigilant, scanning the environment for threats to their safety; conversely they have learned to shut down their feelings.

  The chronicity of the abuse plays a part in the level of anxiety experienced by child victims. Youth who have been assaulted through most of their developmental phases have learned to maintain a defensive posture to protect themselves. They have learned the most debilitating lesson of child abuse: people who love you hurt you. For these children, the expression of caring is presumed to be followed by harm or danger.

  At the end of 4 months of therapy, 6-year-old "Katie," for example, brought a paddle to her therapist. When the therapist asked about the paddle, Katie said, "It is for you to hit me with." When the therapist asked why Katie thought she wanted to hit her, the child replied, "Well you like me, don't you?"

  The sad reality is that children seek out behaviors with which they are familiar. In some instances, children do so to master or take control of situations, thereby reducing their anxiety about what might happen next.

• Hypersensitivity: Young people growing up in violent or abusive environments tend to be hypersensitive to their surroundings. They flinch at sudden noises and are hyperaroused or overstimulated easily. They may experience acute fear in some situations and typically "stay on alert," which requires energy and takes a tremendous toll on their physical and mental well-being. They tend to carry a lot of tension in their bodies, so they may not move as fluidly as other children. Many of these youth present somatic concerns, such as always having headaches or stomach pains.

  Again, the chronicity of the abuse is an important factor in the degree to which young people develop hypersensitivity. If the abuse is an isolated incident, the child is better able to regroup. When the assault is frequent or long term, the child does not have respite to reorganize or stabilize and must develop highly refined defense mechanisms.

• Depression: Even the youngest children who have been abused exhibit characteristics of depression. They may have a flat affect, not make eye contact, or not laugh. There are many manifestations of depression, including self-mutilation, substance abuse, and eating or sleeping disorders.

  The foster parents of a 9-year-old boy reported that he would cut himself and watch the blood run down his arm. A therapist asked what he said to himself when he watched the blood, and the youth replied, "It's red." She asked what he expected to see, and he replied, "guck." Through further questioning, the therapist learned that the boy expected guck to come out of his arm like the bionic man on television.

  This boy thought of himself as a robot, which is a strong defense mechanism against being hurt. When he saw the blood, he actually felt better because he could say, "I'm a real human being." For the next 3 weeks, he would be more interactive, responsive, and happy because he had verified his own existence.

• Alcohol or Drug Use: While some young people may experiment with drugs or alcohol as a rite of passage, youth who were or are abused use substances to numb their feelings.

  The alcoholism of one 6-year-old child was discovered when her preschool reported unusual behaviors to her foster family. The child was given a medical examination, through which the doctors determined that she had been sexually abused.

  She was referred to a therapist who used play therapy. The child would pick the play therapy rag doll up and roll its head back and forth, put one foot in front of the other, as if the doll were walking, and then make it fall. She repeated the sequence 14 times.

  After watching this behavior, the therapist wondered if the child was acting out the behavior of someone who had been drinking. The therapist brought in a small bottle of liquor, the type you get on an airplane, and waved the open bottle under the child's nose, asking if she had ever smelled the odor before. The child grabbed the bottle and tried to drink its contents. Through further questioning, the therapist learned that the child kept a bottle of vodka she had smuggled from her home to the foster residence inside the zipper pouch of a stuffed animal. It turned out that the child's father had given her alcohol in a bottle so that she would relax and go to sleep while he sexually molested her. The child learned that when she drank, she could go to sleep and have the experience of not being "present" while the abuse occurred.

• Problem Sexual Behaviors: Children who were sexually abused may become involved in sexual acting-out behaviors, particularly when they reach adolescence, a time of increasing biological urges and exposure to sexual education. Under normal conditions, sexual behavior develops gradually over time, with youth showing curiosity and then experimenting with themselves and others. When children are sexually abused, however, they are prematurely exposed to material they do not understand and cannot make sense of.

  Moreover, children become conditioned to respond to certain things. In many instances, adults who interact sexually with children may reward them before or after the event. The children are conditioned to believe that if they engage in certain behaviors they will be rewarded. This is pure learning theory: children repeat acts for which they receive positive reinforcement.

  A judge who was doubting the sexual abuse of a 3-year-old child called everyone into his chambers and hoisted the young girl on his lap so that he could interview her. The moment he placed her on his lap, she reached under his robe and began fondling his genitals. She clearly had been conditioned to believe that when a man sits her on his lap, he expects this type of behavior. The judge quickly reversed his opinion and went forward with the case of sexual abuse.

  Some children who were sexually abused also may become sexually provocative, dressing and talking in a manner that puts them at risk of further sexual exploitation. Others merge sexual behavior and aggression and become the victimizers of other children.

• Aggression: Eventually, most abused children get angry and some begin to act aggressively, typically with smaller children. This is the victim-victimizer dynamic; abused children learn that the bigger, stronger person hurts or takes advantage of the smaller, weaker person. Youth who have been victimized are conditioned to believe that when two people interact, one of them will be hurt. At each interaction with others, they may wonder who will be hurt this time. Some children adopt the victim role; others become the victimizers. In either case, they simply are playing out the roles that they have been conditioned to believe people play during interactions with others.

  The research would indicate that boys tend to adopt the role of aggressor more often than girls. They have a harder time tolerating the role of victim, which is in stark contrast to the cultural definition of masculinity. Girls tend to adopt the role of victim more often, which could be linked to the traditional social view of women as the weaker gender. Yet neither pattern holds true in all cases. Some boys take on the victim role; some girls become aggressive.

Obviously, these behaviors and reactions are learned. Young people who have survived sexual abuse can just as easily learn more positive behaviors if communities choose to provide them with appropriate interventions and support. They need support in both working through the trauma and addressing the developmental stages they may have missed because of the abuse. This includes the critical step of developing an identity separate from their family or caretaker.

Identity Formation in Adolescence

Forming an identity is a major developmental issue during adolescence. This process of individuation, however, is one that begins when children are very young and crystallizes in adolescence. For positive identity formation to occur in any human being, some basic things have to be attained, including the following:

• Expressions of Love: Children have to feel that somebody cares about them.
• Feelings of Significance: Children must feel that they are significant or important to someone.
• A Sense of Virtue: Children must have a belief in their innate, inner goodness.
• A Sense of Belonging: Children must feel connected to a family that provides them with a sense of stable belonging.
• Mastery and Control: Children must experience feelings of mastery and personal power and control.

All of these variables are severely compromised by child abuse and neglect. Abused children's sense of self and their future has been badly damaged. They may have learned that negative attention is better than no attention, and they act accordingly. Unfortunately, their behaviors, which result directly from the abuse, often lead significant people in their lives to react in ways that reinforce this negative self-image. This further damages young people's sense of virtue and feeling of being loved.

To deal with these overwhelmingly negative feelings, some children develop an affect disorder, which results from a person compartmentalizing information about an abusive event separately from their feelings. They will describe an abusive event in great detail without emotion, as if it were happening to someone else. This dissociation is a defense mechanism that helps people block reality, especially when it is painful. Children who are being sexually abused use dissociation to separate from their own experiences. They talk about floating above their bodies or sitting on top of a lamp watching what happened.

This process enables a young person not to feel the pain associated with actually being present during the abusive event. Unfortunately, dissociation also creates a problem with a child's sense of identity and interrupts their sense of being anchored in reality.

Children who have an identity problem or no sense of who they are may, for example, develop an insecure attachment disorder. Therapists experience this with young people who ask to see them every day or to come live with them. These young people do not feel real unless they are in another person's presence. Or they fear that the person they are with now will go away and not come back, leading to feelings of abandonment and despair.

When children are not allowed to develop an identity, they may appear as if they are presenting a "false self." These youth simply may not have a good sense of self to present to the world. When with other groups of people, especially other youth with strong personalities, abused children may easily retreat into themselves or mimic those they are around. Helping young people go back through the developmental stages and rebuild a sense of self is critical to their overall emotional well-being.

Treating the Sexually Abused Adolescent

Therapists have identified three stages to working with survivors of childhood abuse:

establishing the young person's safety, both in their home situation and with the therapist;

processing traumatic material; and

fostering social reconnection.

One of a therapist's most important tasks is to ensure that a child is living in a safe environment with a central, supportive, caring adult. Often, young people who have been abused or neglected experience incredible mobility in their lives as they move from one placement to the next. These youth begin to doubt that any adult will be with them for very long. A sense of security and safety in one place, therefore, is very important to the therapeutic process.

Once the child is in a safe environment, the therapist can begin to develop a relationship with the child. Through that relationship, the therapist can begin to help the child understand why it is important to process what happened to them. Most abused adolescents want a sense of control over their lives. Therapists can show youth how, by working through their earlier experience, they can eliminate some of their negative feelings and the resulting behaviors. Through that process, youth can develop a sense of control over their behavior.

When a young person is ready, the therapist can help them begin affiliating with others and developing the ability to trust and have relationships with other people, both adults and peers. Often at this stage, a therapist will place a youth in group therapy.

Time and consistency of care are key factors in all three stages of therapy, but especially in stage 1. By the time an adolescent receives the help they deserve, they may have been sexually or otherwise abused over a period of time. They have built up an array of defenses to protect themselves, and making contact with them may be difficult. To establish the trust of an abused child, a therapist needs to build a relationship with that child, which takes time. Therapists need that time to demonstrate that they are trustworthy, by action as well as words.

In some communities, the new managed care systems are threatening this process by covering the costs of only short-term therapy. The trust of a severely abused child simply cannot be established in six to eight sessions. Under those circumstances, experts caution that therapists should work only on phase 1, or the establishment of the child's safety. It is inappropriate to encourage a child to talk about traumatic abuse if that child is not in a position to receive ongoing therapeutic support.

In such situations, a therapist must simply advocate for children's safe placement and help them to develop coping strategies, teach them about available resources, and suggest behavioral alternatives that may positively affect their interactions with others. A therapist also might help children understand that their behavioral problems may be related to something they learned or experienced a long time ago.

General Principles for Working With Youth Who Have Been Sexually Abused

Helping youth explore past abuse is specialized work, requiring significant education, training, and expertise. The following key principles provide guidance for those working with youth who have been sexually abused:

• Remain Neutral In Your Early Interactions With Abused Children: When some youth sense that a therapist or other professional is paying attention to or trying to help them, they may withdraw because the circumstances feel risky to them. The very nature of counseling or therapy, which involves personal contact with another human being and focused, positive attention, can produce stress and anxiety for children who have been sexually abused. Youth who have been sexually abused also may associate nice behavior with seduction. In the past, people were nice to them when they wanted something. They may wonder what therapists or other adults expect from them in return for their help.
• Assist Youth In Understanding That They Are Not To Blame: Typically, left to their own resources, children make incorrect assumptions about why they were abused or neglected. When 100 youth in San Francisco were asked why they were in the foster care system, 98 of them said, "Because I am bad." And young people's behavior often reflects how they feel about themselves. If they think they are bad, they may act in ways that perpetuate that image.
• Be Nonjudgmental: Youth do not respond well to adults who want to tell them what to do or who are constantly critical.
• Catch Youth Doing Something Good: Focus on telling young people what they are doing that is good. When they make a thoughtful decision and stick to it, for example, congratulate them on following through.
• Help Them View Their Feelings Without Judgment: Feelings are not good or bad, they are just feelings. Help young people understand that it is all right to feel angry, and help them to learn to express their anger in ways that are healthy for themselves and others.
• Think Of Your Interactions With Youth As "Invitations" For Them To Do Or Say As Much Or As Little As They Choose: Youth need to learn to make choices about how they will participate, or not, in different situations. Offering youth options gives them a chance to practice making choices in a safe environment. If a young person does not complete an assignment, for example, consider talking with him or her about what the assignment might have looked like if they had finished it. Or, discuss what might have been the biggest problem in completing the task. Through this process, you might accomplish more than if you focus on the young person's failure to complete the task.
• Avoid Power Struggles With Young People: It generally is nonproductive to spend time arguing a point with an adolescent. Move on to other discussions that might prove more useful. Keep in mind that if a young person is feeling defensive, they are not feeling safe.
• Remember That Abused Adolescents Have A Reason To Be Defensive: If you are hit enough, emotionally or physically, you learn to stand ready to protect yourself or even to ward off attacks by attacking first. Young people who have been abused need time and a trusted relationship to feel safe.
• Understand How Easy It Is For Abused Children To Be Further Victimized: Without question, once abused, children become more vulnerable to further victimization. It is not just the abuse that leaves them exposed to exploitation; it is the concomitant loss of love, nurturing, and feelings of being safe and valued. Often adult predators provide, at least at first, the very things missing from an abused child's history: time, attention, caring, and a sense of belonging.
• Be Aware That Some Behaviors Provide Youth With A Sense Of Control: When children are treated well, nurtured, loved, and accepted, they learn to expect that treatment from others. When children are abused, they similarly expect others will abuse them. These children may engage in aggressive behavior as a defense mechanism; their behavior is a means of taking control of a situation they anticipate will occur anyway. When you work with youth to stop behaviors that place them at risk, it is important to be aware that those behaviors may be the only current means they have for mastery and control.
• Help Educate Others That Young People Are Never Responsible For Their Abuse: Often, people suggest that adolescents should have told someone or fought back. The expectation is that adolescents should be able to protect themselves. It is important to remember that many young people have long histories of abuse, which makes them vulnerable; they are not "normal" (nonabused) adolescents suddenly confronted with dangerous circumstances. Moreover, it is critical to remember that children are relating to their parents, the people they love and need most in the world. When asked, "Who is bad, you or your Mom and Dad?" children will always choose themselves. Children need to protect the idealized image of their parents; those are the people they long for.

Working with youth who have been sexually abused obviously requires special skills and expertise. For that reason, most youth agencies develop strong working relationships with therapists who are experienced in working with youth who have been sexually abused. In selecting a therapist, youth agencies should look for well-trained professionals who understand and apply the above-mentioned principles. They also should look for therapists who do the following:

• Use Therapeutic Approaches Other Than Talk Therapy: Direct talk therapy generally is not the most effective approach with adolescents. Well-trained therapists will use art or play therapy in working with abused youth. They also might discuss news clippings or watch a video and let youth comment on another young person's situation. It may be easier for youth to talk about another person as a means of sharing how they feel. Moreover, helping young people develop empathy for others often can be the first step in developing self-empathy.
• Help Youth Change Behaviors That Cause Negative Reactions In Others: Therapists examine a child's behavior, describe it, and then try to determine why the child is acting in this manner. A 12-year-old girl, for example, who threw temper tantrums explained that she felt quiet inside when the tantrum was over. She said she felt calm because "everything inside had come out." This child had been beaten whenever she showed any emotion, so she had learned to keep her feelings bottled up inside.

  Every now and then, however, she had to let those feelings go. Until she entered therapy, the child had never been taught how to live with and manage real feelings; the result was tension, control, and then loss of control. Her therapist worked with her, using a tea kettle as a metaphor. They jointly developed a plan for the young woman to begin to let her "steam" out in ways that would not cause concern among the people around her or allow the kettle to "blow its lid." Through the process, the young girl learned affect tolerance: the ability to feel, absorb, and express her feelings appropriately.

• Appreciate That Children Sustain Injuries Differently: Some young people are more resilient than others. A therapist needs to assess how well the young person has survived the abuse, what they think about themselves, and how they manage to reach out to others. Through this process, it is important to help the youth build a history of accomplishment by emphasizing the young person's strengths and successes.
• Help Youth Process Traumatic Material: Young people need support to deal with what happened to them, discharge their feelings, and develop a sense of mastery about that process. Unless this happens, images similar to those associated with the abusive event may trigger a posttraumatic stress reaction. A youth may blow up or go into trancelike behavior for no apparent reason. This is an indication that they have unresolved traumatic material and they need help in processing that material in a structured way that creates feelings of empowerment.
• Work With Youth To Assimilate The Information And Feelings Associated With Their Prior Abuse: By processing traumatic material, therapists can help youth talk about the event and feel the associated feelings at the same time.
• Recognize That While Abuse And Neglect Have The Potential To Be Traumatic, Not Every Abused Child Is Traumatized: Traumatized children are a subset of abused children. Factors that distinguish the two groups tend to include the child's relationship to the abuser, age at the onset of abuse, and biology, and the chronicity and severity of the abuse. All abused children are hurt and exploited, but, depending on a broad set of variables, some children continue to live in the climate of the trauma.
• Help Youth Learn How To Manage Their Feelings In Settings In Which It Would Not Be Appropriate To Act Upon Them: Some youth need to learn affect regulation, which is the ability to control feelings in certain situations. Adults, for example, who had a fight with a spouse prior to making a presentation at work are able to refocus themselves. They are able to control the feelings they are experiencing as a result of the fight while they make the presentation.
• Work With Youth To Develop Impulse Control: Children growing up with abusive parents did not have impulse control modeled for them. Many abusive parents think and act at the same time; when they are angry, they strike their children. Nonabusive parents also get angry at their children; they simply have the impulse control not to act on every thought. Children who grew up with abusive parents may need to learn that thoughts and action can be distant on the time spectrum. They need help in determining how to go through a series of steps to make decisions about what they will do in response to their thoughts.
• Accept That All Children Are Different: Some children act out in ways that continue the climate of trauma through behavioral reenactments that keep the victim dynamic present in their life. Others want to talk constantly about the abuse and will do so even with strangers. Still other youth refuse to talk about the abuse; they say it is over and they do not want to deal with it. A good therapist will develop a plan for working with a young person on the basis of that child's behavior, presenting problems, personality
  

Today, 66 percent of adults in the United States are considered overweight or obese. Obesity puts people at increased risk for chronic diseases such as heart disease, type 2 diabetes, high blood pressure, stroke, and some forms of cancer.

The large number of people considered to be obese and the serious health risks that come with it make understanding its causes and treatment crucial. This fact sheet provides basic information about obesity: What is it? How is it measured? What causes it? What are the health risks? What can you do about it?

What is obesity?

"Obesity" specifically refers to an excessive amount of body fat. "Overweight" refers to an excessive amount of body weight that includes muscle, bone, fat, and water. There are few studies in humans that link direct measurements of total body fat to morbidity and mortality. There are also no official standards identified by the National Institutes of Health (NIH) that define obesity based on the amount or percentage of a person's total body fat.

How is obesity measured?

Measuring the exact amount of a person's body fat is not easy. The most accurate measures are to weigh a person underwater or in a chamber that uses air displacement to measure body volume, or to use an X-ray test called Dual Energy X-ray Absorptiometry, also known as DEXA. These methods are not practical for the average person, and are done only in research centers with special equipment.

There are simpler methods to estimate body fat. One is to measure the thickness of the layer of fat just under the skin in several parts of the body. Another involves sending a harmless amount of electricity through a person's body. Results from these methods, however, can be inaccurate if done by an inexperienced person or on someone with extreme obesity.

Because measuring a person's body fat is difficult, health care professionals often rely on other means to diagnose obesity. Weight-for-height tables, used for decades, have a range of acceptable weights for a person of a given height. One problem with these tables is that there are many versions, all with different weight ranges. Another problem is that they do not distinguish between excess fat and muscle. According to the tables, a very muscular person may be classified obese when he or she is not. The Body Mass Index (BMI) is less likely to misidentify a person's appropriate weight-for-height range.

Body Mass Index

The BMI is a tool used to assess overweight and obesity and monitor changes in body weight. Like the weight-for-height tables, BMI has its limitations because it does not measure body fat or muscle directly. It is calculated by dividing a person's weight in pounds by height in inches squared and multiplied by 703.

Men and women can have the same BMI but different body fat percentages. As a rule, women usually have more body fat than men. A bodybuilder with a large muscle mass and low percentage of body fat may have the same BMI as a person who has more body fat. However, a BMI of 30 or higher usually indicates excess body fat.

Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. Then look to find your weight group.

Body Fat Distribution

Health care professionals are concerned not only with how much fat a person has, but also where the fat is located on the body. Women typically collect fat in their hips and buttocks, giving them a "pear" shape. Men usually build up fat around their bellies, giving them more of an "apple" shape. Of course, some men are pear-shaped and some women become apple-shaped, especially after menopause.

Excess abdominal fat is an important, independent risk factor for disease. Research has shown that waist circumference is directly associated with abdominal fat and can be used in the assessment of the risks associated with obesity or overweight. If you carry fat mainly around your waist, you are more likely to develop obesity-related health problems.

Women with a waist measurement of more than 35 inches and men with a waist measurement of more than 40 inches may have more health risks than people with lower waist measurements because of their body fat distribution.

Causes of Obesity

Obesity occurs when a person consumes more calories from food than he or she burns. Our bodies need calories to sustain life and be physically active, but to maintain weight we need to balance the energy we eat with the energy we use. When a person eats more calories than he or she burns, the energy balance is tipped toward weight gain and obesity. This imbalance between calories-in and calories-out may differ from one person to another. Genetic, environmental, and other factors may all play a part.

Genetic Factors

Obesity tends to run in families, suggesting a genetic cause. However, families also share diet and lifestyle habits that may contribute to obesity. Separating genetic from other influences on obesity is often difficult. Even so, science does show a link between obesity and heredity.

Environmental and Social Factors

Environment strongly influences obesity. Consider that most people in the United States alive today were also alive in 1980, when obesity rates were lower. Since this time, our genetic make-up has not changed, but our environment has.

Environment includes lifestyle behaviors such as what a person eats and his or her level of physical activity. Too often Americans eat out, consume large meals and high-fat foods, and put taste and convenience ahead of nutrition. Also, most people in the United States do not get enough physical activity.

Environment also includes the world around us - our access to places to walk and healthy foods, for example. Today, more people drive long distances to work instead of walking, live in neighborhoods without sidewalks, tend to eat out or get "take out" instead of cooking, or have vending machines with high-calorie, high-fat snacks at their workplace. Our environment often does not support healthy habits.

In addition, social factors including poverty and a lower level of education have been linked to obesity. One reason for this may be that high-calorie processed foods cost less and are easier to find and prepare than healthier foods, such as fresh vegetables and fruits. Other reasons may include inadequate access to safe recreation places or the cost of gym memberships, limiting opportunities for physical activity. However, the link between low socioeconomic status and obesity has not been conclusively established, and recent research shows that obesity is also increasing among high-income groups.

Cultural Factors

An individual's cultural background may also play a role in his or her weight. For instance, foods specific to certain cultures that are prepared with a lot of fat or salt may hamper one's weight-loss efforts. Similarly, family gatherings offering large amounts of food may make it difficult to pay attention to proper portion control and serving sizes. Lastly, research has shown that individuals originally from countries other than the United States have difficulty adjusting to the calorie-rich foods offered here. These individuals may not be able to prepare food with the ingredients they would use in their native countries.

Although you cannot change your genetic makeup, you can work on changing your eating habits, levels of physical activity, and other environmental factors. Try these ideas:

• Learn to choose sensible portions of nutritious meals that are lower in fat.
• Learn healthier ways to make your favorite foods.
• Learn to recognize and control environmental cues (like inviting smells or a package of cookies on the counter) that make you want to eat when you are not hungry.
• Have a healthy snack an hour or two before a social gathering to prevent overeating. Mingle and talk between bites to prevent eating too much too quickly.
• Engage in at least 30 minutes of moderate-intensity physical activity (like brisk walking) on most, preferably all, days of the week.
• Take a walk instead of watching television.
• Eat meals and snacks at a table, not in front of the TV.
• Pay attention to why you are eating. Determine if you are eating because you are actually hungry or because you are bored, depressed, or lonely.
• Keep records of your food intake and physical activity.

Other Causes of Obesity

Some illnesses may lead to or are associated with weight gain or obesity. These include:

• Hypothyroidism, a condition in which the thyroid gland fails to produce enough thyroid hormone. It often results in lowered metabolic rate and loss of vigor.
• Cushing's syndrome, a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol. Symptoms vary, but most people have upper body obesity, rounded face, increased fat around the neck, and thinning arms and legs.
• Polycystic ovary syndrome, a condition characterized by high levels of androgens (male hormone), irregular or missed menstrual cycles, and in some cases, multiple small cysts in the ovaries. Cysts are fluid-filled sacs.

A doctor can tell whether there are underlying medical conditions that are causing weight gain or making weight loss difficult.

Lack of sleep may also contribute to obesity. Recent studies suggest that people with sleep problems may gain weight over time. On the other hand, obesity may contribute to sleep problems due to medical conditions such as sleep apnea, where a person briefly stops breathing at multiple times during the night. (Visit http://www.win.niddk.nih.gov/publications/health_risks.htm#sleep for more information on the relationship between sleep apnea and obesity.) You may wish to talk with your health care provider if you have difficulty sleeping.

Certain drugs such as steroids, some antidepressants, and some medications for psychiatric conditions or seizure disorders may cause weight gain. These drugs may slow the rate at which the body burns calories, stimulate appetite, or cause the body to hold on to extra water. Be sure your doctor knows all the medications you are taking (including over-the-counter medications and dietary supplements). He or she may recommend a different medication that has less effect on weight gain.

Consequences of Obesity

Health Risks

Obesity is more than a cosmetic problem. Many serious medical conditions have been linked to obesity, including type 2 diabetes, heart disease, high blood pressure, and stroke. Obesity is also linked to higher rates of certain types of cancer. Men who are considered obese are more likely than nonobese men to develop cancer of the colon, rectum, or prostate. Women who are considered obese are more likely than nonobese women to develop cancer of the gallbladder, uterus, cervix, or ovaries. Esophageal cancer has also been associated with obesity.

Other diseases and health problems linked to obesity include:

• Gallbladder disease and gallstones.
• Fatty liver disease (also called nonalcoholic steatohepatitis or NASH).
• Gastroesophageal reflux, or what is sometimes called GERD. This problem occurs when the lower esophageal sphincter does not close properly and stomach contents leak back - or reflux - into the esophagus.
• Osteoarthritis, a disease in which the joints deteriorate. This is possibly the result of excess weight on the joints.
• Gout, another disease affecting the joints.
• Pulmonary (breathing) problems, including sleep apnea, which causes a person to stop breathing for a short time during sleep.
• Reproductive problems in women, including menstrual irregularities and infertility.

Health care professionals generally agree that the more obese a person is, the more likely he or she is to develop health problems.

Psychological and Social Effects

Emotional suffering may be one of the most painful parts of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages may make people considered overweight feel unattractive.

Many people think that individuals who are considered obese are gluttonous, lazy, or both. This is not true. As a result, people who are considered obese often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection, shame, or depression may occur.

Who should lose weight?

Health care professionals generally agree that people who have a BMI of 30 or greater can improve their health through weight loss. This is especially true for people with a BMI of 40 or greater, who are considered extremely obese.

Preventing additional weight gain is recommended if you have a BMI between 25 and 29.9, unless you have other risk factors for obesity-related diseases. Obesity experts recommend you try to lose weight if you have two or more of the following:

• Family history of certain chronic diseases. If you have close relatives who have had heart disease or diabetes, you are more likely to develop these problems if you are obese.
• Preexisting medical conditions. High blood pressure, high LDL cholesterol levels, low HDL cholesterol levels, high triglycerides, and high blood glucose are all warning signs of some obesity-associated diseases.
• Large waist circumference. Men who have waist circumferences greater than 40 inches, and women who have waist circumferences greater than 35 inches, are at higher risk of diabetes, dyslipidemia (abnormal amounts of fat in the blood), high blood pressure, and heart disease.

Fortunately, a weight loss of 5 to 10 percent of your initial body weight can do much to improve health by lowering blood pressure and other risk factors for obesity-related diseases. In addition, research shows that a 5- to 7-percent weight loss brought about by moderate diet and exercise can delay or possibly prevent type 2 diabetes in people at high risk for the disease. In a recent study, participants who were considered overweight and had pre-diabetes - a condition in which a person's blood glucose level is higher than normal, but not high enough to be classified as diabetes - were able to delay or prevent the onset of type 2 diabetes by adopting a low-fat, low-calorie diet and exercising for 30 minutes a day, 5 days a week.

How is obesity treated?

The method of treatment depends on your level of obesity, overall health condition, and readiness to lose weight. Treatment may include a combination of diet, exercise, behavior modification, and sometimes weight-loss drugs. In some cases of extreme obesity, bariatric surgery may be recommended. (Visit http://www.win.niddk.nih.gov/publications/gastric.htm for more information on bariatric surgery.)

Remember, weight control is a life-long effort, and having realistic expectations about weight loss is an important consideration. Eating healthier foods and getting at least 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week have important health benefits. Sixty minutes of physical activity a day may be required to prevent gradual weight gain in adulthood. Individuals who were previously considered overweight and obese individuals are encouraged to get 60 to 90 minutes of exercise a day to sustain weight loss.

Although most adults do not need to see their health care professional before starting a moderate-intensity physical activity program, men older than 40 years and women older than 50 years who plan a vigorous program, or who have either chronic disease or risk factors for chronic illnesses, should speak with their health care provider before starting a physical activity program.

Source

Weight-control Information Network
1 Win Way
Bethesda, MD 20892-3665
Phone: (202) 828-1025
FAX: (202) 828-1028
E-mail: [email protected]
Internet: http://www.win.niddk.nih.gov
Toll-free number: 1-877-946-4627

The Weight-control Information Network (WIN) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, which is the Federal Government's lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103-43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information on weight control, obesity, physical activity, and related nutritional issues.

Publications produced by WIN are carefully reviewed by both NIDDK scientists and outside experts. This fact sheet was also reviewed by Steven N. Blair, Professor, Department of Exercise Science, Arnold School of Public Health, University of South Carolina.

This publication is not copyrighted. WIN encourages users of this brochure to duplicate and distribute as many copies as desired.

Adapted from NIH Publication No. 06-3680
November 2008

Reviewed by athealth on February 8, 2014.

The growth in the number of people age 60 and older will bring a soaring increase in the amount and cost of primary and specialty care for this group. In 1990, those over the age of 65 comprised 13 percent of the U.S. population; by the year 2030, older adults are expected to account for 22 percent of the population (U.S. Bureau of the Census 1996). Community surveys have estimated the prevalence of problem drinking among older adults to range from 1 percent to 15 percent (Adams et al. 1996; Fleming et al. 1999; Moore et al. 1999). Among older women, the prevalence of alcohol misuse ranged from less than 1 percent to 8 percent in these studies. As the population age 60 and older increases, so too could the rate of alcohol problems in this age group. However, early detection efforts by health care providers can help limit the prevalence of alcohol problems and improve overall health in older adults.

Many of the acute and chronic medical and psychiatric conditions that lead to high rates of health care use by older people are influenced by the consumption of alcohol. These conditions include harmful medication interactions, injury, depression, memory problems, liver disease, cardiovascular disease, cognitive changes, and sleep problems (Gambert and Katsoyannis 1995). For example, Thomas and Rockwood (2001) found that the occurrence of all types of dementia (with the exception of Alzheimer's disease) was higher in a sample of 2,873 people age 65 and older with definite or questionable alcohol abuse¹ compared with those who did not abuse alcohol. (¹ Based on interview results and criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994).) At 18 months after baseline, mortality from all causes in this sample was higher among those with definite abuse (14.8 percent) or questionable abuse (20 percent) than among those with no alcohol abuse history (11.5 percent). The risk for negative alcohol-related health effects is greater for older women than for older men at the same amounts of alcohol use.

Researchers have recently recommended that screening and interventions focused on lifestyle factors, including the use of alcohol, may be the most appropriate way to maximize health outcomes and minimize health care costs among older adults (Blow 1998; Barry et al. 2001). For example, primary health care providers can screen patients for alcohol problems and offer brief intervention - 5- to 15-minute sessions of information and advice about the risks of drinking and how to reduce drinking - to help prevent at-risk drinkers from developing alcohol problems. In randomized clinical trials, women have been found to benefit most from brief interventions (Fleming et al. 1997, 1999).

This article examines alcohol use among older women, related risk factors and beneficial effects, screening methods to detect alcohol problems in this population, and treatment and prevention approaches.

Older Women Have Increased Risks for Alcohol Problems

Older women tend to have longer life expectancies and to live alone longer than men, and they are less likely than men in the same age group to be financially independent. These physical, social, and psychological factors are sometimes associated with at-risk drinking in older adulthood, so they are especially relevant for older women.

Older women have major physical risk factors that make them particularly susceptible to the negative effects of increased alcohol consumption (Blow 1998). Women of all ages have less lean muscle mass than men, making them more susceptible to the effects of alcohol. In addition, there is an age-related decrease in lean body mass versus total volume of fat, and the resultant decrease in total body mass increases the total distribution of alcohol and other mood-altering chemicals in the body. Both men and women experience losses in lean muscle mass as they age, but women have less lean muscle mass than men throughout adulthood and, therefore, are less able to metabolize alcohol throughout their lives, including into older adulthood (see Blow 1998 for further information). Liver enzymes that metabolize alcohol and certain other drugs become less efficient with age, and central nervous system sensitivity increases with age for both genders. In sum, compared with younger adults, and with older men, older women have an increased sensitivity to alcohol.

Older women also have a heightened response to over-the-counter and prescription medications (Smith 1995; Vestal et al. 1977; Blow 1998). The use and misuse of alcohol and prescription medications are therefore especially risky for women as they age because of their specific vulnerabilities regarding sensitivity to alcohol and medications. For most patients, any alcohol consumption coupled with the use of specific over-the-counter or prescription medications can be a problem. For example, combining alcohol with psychoactive medications such as benzodiazepines, barbiturates, and antidepressants can be especially problematic for this population. Older women are more likely than older men to receive prescriptions for benzodiazepines in particular, and are therefore more likely to be faced with problems related to the interaction of these medications with alcohol (see Blow 1998 for further discussion). There is a paucity of data available on rates of the co-occurrence of alcohol and medication use in older people. This area needs more study.

Because older women generally drink less than older men or abstain from alcohol, health care providers may be less likely to recognize at-risk drinking and alcohol problems in this population. Moreover, few elderly women who abuse alcohol seek help in specialized addiction treatment settings. These problems stand in the way of effective interventions that can improve the quality of life of older women drinking at risky levels.

The following sections will first examine the prevalence of problem drinking in older women and then review the risks and benefits associated with alcohol use among older women. The article concludes with a discussion of screening and interventions for this population.

Prevalence of the Problem

As stated above, community surveys have estimated that at-risk drinking ranges from 1 percent to 15 percent among older adults and that from 1 percent to 8 percent of older women misuse alcohol (Adams et al. 1996; Fleming et al. 1999; Moore et al. 1999). The wide variation of these ranges results from varying definitions of problem drinking and alcohol misuse and from the methodology used in selecting the survey respondents.

The rates of illegal drug abuse among the older population are very low. Because of the dearth of information in this area, actual rates are difficult to measure (Blow 1998). Future research will more completely address the use of alcohol and illegal drugs in older adulthood (Blow 1998).

Prescription drug misuse is more common and has multiple determinants, causes, and consequences. For example, older adults may be experiencing problems related to overuse of prescription drugs because they are prescribed more medication than they can tolerate at that age, or because they are seeking prescriptions for a particular medication (e.g. benzodiazepine) from multiple providers.

Risk and Benefits Associated with Alcohol Use by Older Women

Research provides evidence that one drink² per day (i.e., moderate drinking) is associated with certain health benefits among older adults generally and among older women, whereas higher levels of drinking are associated with health risks. (² A standard drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.) Only a few studies have either focused on women or have included sufficient numbers of older women to be conclusive about the effects for this population (Abramson et al. 2001). Therefore, this section includes studies on older adults in general and on women in particular.

Risks

A recent study of moderate and heavy drinking among older adults found that study participants reported poorer psychosocial functioning with increasing daily alcohol consumption (Graham and Schmidt 1999). The frequency of drinking (drinking days per week), however, was not related to psychosocial well-being, suggesting that the amount of alcohol consumption was a more significant factor. Ensrud and colleagues (1994) found that, among older women, those with a history of regular alcohol use were 2.2 times more likely to have impaired activities of daily living compared with those with no history of regular alcohol use. Alcohol use was more strongly correlated with impairment than were smoking, age, use of antianxiety medication, or stroke.

Although several studies have examined the role of alcohol use in cardiac problems, stroke, and cancers, most of these studies have not included older women. A study using National Cholesterol Education Program data found that, among the women in the study, failure to use lipid-lowering medications was associated with alcohol consumption and smoking, among other factors (Schrott et al. 1997). In a study of postmenopausal women in the Iowa Women's Health Study, Sellers and colleagues (2002) estimated the interaction of folate intake from diet and alcohol consumption at baseline for 34,393 study participants to determine the risk for specific types of breast cancer. The study compared women with low folate levels and higher alcohol consumption (i.e., more than 4 grams per day)³ with nondrinkers who had a high folate intake. (³ There are 12 grams of alcohol in a standard drink in the United States.) The authors found that the combination of alcohol use and low folate levels produced an increase in the risk of one type of tumor. A recent meta-analysis examined 53 epidemiological studies of the relationships between alcohol use, smoking, and breast cancer (Collaborative Group on Hormonal Factors in Breast Cancer 2002), including 58,515 women with breast cancer and 95,067 women without the disease. This study found that, compared with women who reported drinking no alcohol, the relative risk was 1.32 for those who drank 35 to 44 grams of alcohol per day (3 to 3.6 standard drinks), and 1.46 for those who drank more than 45 grams per day (3.75 standard drinks). A relative risk of 1.32 corresponds to a 32-percent higher risk. The relative risk of breast cancer increased by 7.1 percent for every 10 grams of alcohol consumed per day.

Epidemiological studies have clearly demonstrated that comorbidity between alcohol use and psychiatric symptoms is common in younger age groups. Less is known about comorbidity between alcohol use and psychiatric illness in later life. A few studies have indicated that a dual diagnosis with alcoholism is an important negative predictor of outcomes among the elderly (Blow 1998; Saunders et al. 1991; Finlayson et al. 1988). Because women are twice as likely as men to experience depression, and older women often experience several life losses that can exacerbate depression and the use of alcohol, it is important for health care providers to be aware of the potential for comorbid depression and alcoholism in this population and to keep potential comorbid factors in mind when conducting health screenings with older women, particularly when they are experiencing some of the difficult personal losses associated with aging.

Benefits

There is growing evidence that, among otherwise healthy adults, especially middle-aged adults, moderate alcohol use may reduce risks of cardiovascular disease (Scherr et al. 1992; Thun et al. 1997), some dementing illnesses, and some cancers (Broe et al. 1998; Orgogozo et al. 1997; Klatsky et al. 1997). Simons and colleagues (2000) found that moderate alcohol intake (from 1 to 14 drinks per week) in older men and women was associated with decreased mortality. Nelson and colleagues (1994) have demonstrated that older people living in the community (not in institutions) who consume moderate amounts of alcohol have fewer falls, greater mobility, and improved physical functioning when compared with nondrinkers. One of the factors affecting the disparities between the results of various studies on this topic may be the setting for the study (e.g., community, subsidized housing, assisted living situation, or institution).

In a meta-analysis of studies of alcohol's effect on coronary heart disease, Mukamal and Rimm (2001) found that two drinks per day increased high-density lipoprotein (HDL) cholesterol levels, translating to a 16.8-percent decreased risk of coronary heart disease. Additionally, a study of women with coronary heart disease found that older age, alcohol consumption, and prior estrogen use were all independently associated with higher HDL cholesterol (Bittner et al. 2000).

The debate regarding the benefits and liabilities of alcohol use for older women continues. As new studies include larger numbers of older women, definitive recommendations regarding the relationships between alcohol use and cancers, stroke, cardiac diseases, and risk of psychiatric comorbidities will become more feasible.

Based on the risk factors associated with alcohol use by older women, drinking guidelines for this population are lower than those set for other adults, as reviewed in the next section.

Drinking Guidelines and Rationale

Because of the age-related changes in how alcohol is metabolized and the potential interactions between medications and alcohol, alcohol use recommendations for older adults are generally lower than those set for adults younger than age 65. Recommendations for women are slightly lower than those for men as they age.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Center for Substance Abuse Treatment (CSAT) (Blow 1998) recommend that people age 65 and older consume no more than one standard drink per day or seven standard drinks per week (Dufour and Fuller 1995).

These recommendations are consistent with the current evidence weighing the risks and beneficial health effects of drinking (Klatsky et al. 1997; Mukamal and Rimm 2001). To put these recommendations into perspective, the guidelines for adults younger than age 65 are as follows: for women, no more than one standard drink per day; for men, no more than two standard drinks per day (U.S. Department of Health and Human Services and U.S. Department of Agriculture 1995).

Definitions

Before discussing screening and intervention, it is important to define the various levels of drinking. These definitions help anchor clinical decisions regarding when and if interventions are needed. Drinking that exceeds the guidelines will not always lead to alcohol-related problems, particularly for people who are drinking a few drinks above recommended limits but not at levels that can put them at risk for alcohol dependence. It is, however, useful to consider a model indicating that the more alcohol a person consumes, the more likely that person is to have alcohol-related problems (Institute of Medicine 1990). Categories of drinking risk presented here - low-risk drinking, at-risk drinking, problem drinking, and alcohol dependence - are based on that conceptualization and form a framework for understanding the spectrum of use seen in older women (Blow 1998; Barry et al. 2001).

Abstinence. Approximately 60 to 70 percent of older adults (70 to 80 percent of older women) abstain from drinking. Reasons for abstinence may include religious beliefs, illnesses, or previous problems with alcohol use. Alcohol-use interviews ascertain the reasons for nonuse.

Low-risk drinking is low-level alcohol use that is not problematic. Older women in this category drink within recommended drinking guidelines (less than one drink per day or seven drinks per week), are able to employ reasonable limits on alcohol consumption, and do not drink when driving a motor vehicle or when using medications that may interact with alcohol.

Low-risk use of medications or other drugs would include using medications following the physician's prescription. However, screening should include a check on the number and types of medications a person is using and her concomitant use of alcohol, because interactions between medications and alcohol are not uncommon in older women.

At-risk drinking increases the chance that a person will develop drinking-related problems. Women age 65 and older who drink more than one drink per day are in the at-risk use category. Brief advice or brief interventions can be useful for women in this group.

Problem drinking among older women is defined as the consumption of alcohol at a level that has already resulted in adverse medical, psychological, or social consequences. Potential consequences may include injuries, medication interaction problems, and family problems. The presence of consequences, whether or not the person's drinking exceeds the recommended guideline, also suggests a need for intervention.

Alcohol abuse and dependence are disorders characterized by specific criteria. Alcohol abuse is characterized by continued drinking despite negative consequences and the inability to fulfill responsibilities. Alcohol dependence, also known as alcoholism, is characterized by loss of control, preoccupation with alcohol or other drugs, and physiological symptoms such as tolerance and withdrawal (American Psychiatric Association [APA] 1994). Women age 65 and older who have alcohol abuse or dependence disorders can benefit greatly from treatment, especially elder-specific programs (Blow et al. 2000; Schonfeld et al. 2000)

Screening and Detection of Alcohol Problems in Older Women

CSAT (Blow 1998) has recommended that everyone age 60 and older should be screened for alcohol and prescription drug use and abuse as part of regular health care services. People should continue to be screened yearly unless certain physical or mental health symptoms emerge during the year, or unless they are undergoing major life changes or transitions, at which time additional screenings should be conducted. The textbox lists some of the signs and symptoms of alcohol problems seen in older women. Many of these signs can be related to other problems that occur in later life, but it is important to rule alcohol use in or out of any diagnosis.

Signs and Symptoms of Alcohol Problems in Older Women Anxiety Increased tolerance to alcohol or medications Depression, mood swings Memory loss Disorientation New difficulties in decisionmaking Poor hygiene Falls, bruises, burns Family problems Idiopathic seizures (i.e., seizures with an unknown origin or cause) Financial problems Sleep problems Headaches Social isolation Incontinence Poor nutrition SOURCE: Adapted from Barry et al. 2001.

The goals of screening are to identify at-risk drinkers, problem drinkers, or people with alcohol abuse or dependence disorders and to determine the need for further assessment. Screening can take place in a variety of settings including primary care, specialty care, and social service and emergency departments. Alcohol screening can be conducted because the incidence of alcohol problems is high enough to justify the cost, alcohol can adversely affect morbidity and mortality, and valid, cost-effective screening methods and effective treatments are available.

Systems (e.g., automatic yearly administration of alcohol screening instruments) to ensure that older women in health care settings are screened for alcohol use and consequences are necessary for prevention and early intervention efforts. These systems must include screening for alcohol use (frequency and quantity), drinking-related consequences, medication use and alcohol/medication interaction problems, and depressed feelings. Screening may be conducted as part of routine mental and physical health services and can be updated annually. Screening should also take place before a patient begins taking any new medications or in response to problems that may be related to alcohol or medication.

Clinicians can obtain more accurate patient histories by asking questions about the recent past and by asking the alcohol use questions in the context of other health variables (e.g., exercise, weight, smoking). Alcohol (and other drug) screening for older patients should be simple and consistent with other screening procedures already in place.

Screening for alcohol use and related problems is not always standardized, and not all standardized instruments are reliable and valid with older women. The Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) (Blow et al. 1998), which consists of quantity and frequency questions embedded with questions about other health habits (see Blow 1998 for a review of screening instruments for older adults), and the newer Alcohol-Related Problems Survey (Moore et al. 1999) are both valid and reliable instruments with older adults. The CAGE⁴ (Ewing 1984), a widely used alcohol screening test, does not have high validity with older adults, in particular with older women (Adams et al. 1996). (⁴ The CAGE screening instrument (Ewing 1984) consists of four questions: Have you ever felt you should Cut down on your drinking?; Have people Annoyed you by criticizing your drinking?; Have you ever felt bad or Guilty about your drinking?; Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?)

Prevention, Brief Intervention, and Formal Treatment with Older Women

For years, screening and brief intervention have been suggested as cost-effective and practical techniques that can be used with at-risk and problem drinkers in primary care settings. CSAT has defined brief alcohol interventions as time limited (from 5 minutes to five brief sessions) and targeting a specific health behavior (at-risk drinking) (Barry 1999). Over the last two decades, more research has evaluated the effectiveness of early problem detection and secondary prevention (i.e., preventing existing problems from getting worse). Such studies have evaluated brief intervention strategies for treating problem drinkers, especially those with relatively mild-to-moderate alcohol problems who are potentially at risk for developing more severe problems (Fleming et al. 1997).

Brief Alcohol Intervention Goals

Brief intervention typically includes setting flexible drinking goals that allow the patient, with guidance from the clinician, to choose drinking moderation or abstinence. The goal of brief intervention is to motivate at-risk and problem drinkers to change their behavior - that is, to reduce or stop alcohol consumption. In some cases, when formal treatment is warranted, the goal is to facilitate treatment entry. Terminology can be particularly important when working with older women. The stigma and shame associated with the term "alcoholic" can be a powerful deterrent to seeking help. Avoiding pejorative terms provides a positive framework for clinicians and can help empower older women with risky alcohol or medication use to make changes, thereby reducing the negative feelings often associated with drinking problems.

Brief alcohol interventions can be conducted using guidelines and steps (Barry et al. 2001) adapted from work by Wallace and colleagues (1988), Fleming and colleagues (1997), and Blow and Barry (2000). Brief alcohol intervention protocols are designed for busy clinicians and often use a workbook that the patient can take home at the end of the session. Auxiliary issues included in the brief alcohol intervention for older women vary based on individual patient issues and the time available for the intervention.

Effectiveness of Brief Alcohol Interventions with Older At-Risk Drinkers

The spectrum of alcohol intervention for older adults ranges from prevention/education for abstinent or low-risk drinkers and minimal advice or brief structured interventions for at-risk or problem drinkers to formal alcoholism treatment for drinkers who meet the criteria for alcohol abuse or dependence (Blow 1998). Although referral to formal treatment is appropriate for patients with alcohol abuse or dependence, pretreatment strategies are also appropriate for this population. Pretreatment strategies include the use of brief interventions to help patients discriminate between their alcohol use and the problems resulting from that use (Barry 1999).

Brief interventions for alcohol problems (for all populations) have employed various approaches to change drinking behaviors. Strategies have ranged from relatively unstructured counseling and feedback to more formal structured therapy (see Barry 1999 for a review) and have relied heavily on concepts and techniques from the behavioral self-control training literature (Miller and Rollnick 1991).

Several brief alcohol intervention studies conducted in primary care settings with younger adults have shown mainly positive results. Both brief interventions and brief therapies (usually delivered by mental health professionals to people in substance abuse or mental health treatment) have been found to be effective in a range of clinical settings including primary care, mental health treatment, hospital, senior housing, and senior centers (Barry 1999). Although fewer studies with older adults are available, two existing studies suggest that brief intervention is useful with the older population as well. Fleming and colleagues (1999) and Blow and Barry (2000) used brief interventions in randomized clinical trials in primary care settings to reduce hazardous drinking among older adults. These studies have shown that older adults can be engaged in brief intervention, that this technique is acceptable in this population, and that there is a substantial reduction in drinking among at-risk drinkers receiving the interventions compared with a control group.

The first study, Project GOAL: Guiding Older Adult Lifestyles (Fleming et al. 1999), was a randomized controlled clinical trial conducted in Wisconsin with 158 older adults ages 65 to 88, 53 (34 percent) of whom were women. All patients age 65 and older in a number of primary care sites were asked to complete a screening questionnaire. Those who screened positive for at-risk drinking (i.e., those who exceeded recommended drinking guidelines) were randomized to an intervention group and a control group. One hundred forty-six subjects participated in the 12-month followup. The intervention consisted of two 10- to 15-minute counseling visits during which the physician delivering the intervention followed a scripted workbook; the patients were given advice and information and asked to sign a contract designed to reinforce drinking goals. At baseline, both groups consumed an average of 15 to 16 drinks per week. After 12 months, patients in the intervention group drank significantly less than those in the control group, decreasing their consumption by about 30 percent. Because the proportion of women in the study was small, major analyses focused on the entire sample of men and women together.

The second elder-specific study, the Health Profile Project, was conducted in primary care settings in southeast Michigan (Blow and Barry 2000). Examining a sample that included patients age 55 and older, researchers sought to determine whether changes in drinking patterns and response to interventions occurred both in older adulthood (older than 65) and in the transitional phase from ages 55 to 65. The older-adult-specific intervention, used with both groups for consistency, included both a brief advice discussion with a psychologist or social worker and motivational interviewing techniques, and feedback. A total of 420 people participated (including those who received the intervention and the control group) in this trial, and 367 participated in 12-month followup interviews. Seventy-three women were enrolled in the study at baseline, and 69 participated in the 12-month followup. The mean age of the female participants was 67.

The study found results similar to the study by Fleming and colleagues (1999) for binge drinking (i.e., drinking four or more drinks per occasion) and drinking days per week, in particular, at 12-month followup. At followup, the intervention group of women averaged 7 drinks per week (within recommended guidelines) and the control group averaged 8.2 drinks per week. Although the intervention group lowered its consumption to within NIAAA guidelines, the groups were not statistically different at followup. Nor did the groups differ significantly in terms of drinks per day at baseline or followup. The fact that the intervention and control group did not differ in drinks per drinking day at 12 months after intervention could indicate natural minimal changes over time in behaviors for both groups. However, there were statistically significant differences between the groups in days per week (frequency) of drinking from baseline to 12 months. On average, subjects in the intervention group decreased their drinking from 4.5 days per week at baseline to 3.1 days per week at 12 months; the control subjects drank an average of 4.3 days per week at baseline and only decreased to 3.6 days per week at 12-month followup. The intervention group showed significantly more days of abstinence per week at 12 months, indicating diminished risk. Days of abstinence are recommended for reducing risk (Barry et al. 2001).

These randomized controlled clinical trials extend the positive results of research on younger at-risk drinkers to the older at-risk drinking population by showing that, regardless of age, brief interventions are effective in assisting older at-risk drinkers to drink less often. The studies provide a good basis for future research focused on older women who use alcohol and on the interaction between alcohol and medications in this age group. Research is needed to determine the most effective components of brief interventions with older women and the most effective venues (e.g., primary care, in-home, senior center, senior housing). Research is also needed to address an under-studied area, the interaction between alcohol and medications in older women, and to determine the best methods for dealing with this more complex problem.

Because the population of older women is increasing rapidly and rates of alcohol misuse are anticipated to increase with the aging of the Baby Boom generation, alcohol researchers need to find methods to include larger numbers of older women in studies. Randomized trials with larger sample sizes will provide a more complete picture of the characteristics of women who respond to brief interventions as well as the most effective education and prevention methods for this population.

Formal, Specialized Treatment Approaches for Older Women

CSAT has recommended several approaches for the effective formal treatment of older women and men with alcohol problems. These include cognitive behavioral approaches, group–based approaches, individual counseling, medical/psychiatric approaches, marital and family involvement/family therapy, case management/community–linked services and outreach, and formal alcoholism treatment.

As with all other clinical issues, not every approach fits every older woman with alcohol abuse or dependence. Ideally, treatment should be individualized for the specific person, taking into account his or her medical, psychiatric, social, and cultural needs. Most of the therapeutic approaches included here have been more widely studied in younger adults (Blow 1998). Only a few elder–specific studies have evaluated intervention/treatment methods other than brief intervention for at–risk drinkers and formal treatment for people with alcohol abuse or dependence. There has been even less of a focus on older women, in part because fewer older women meet criteria for formal treatment and because fewer women who need treatment are identified by primary providers and referred to treatment. A few examples of elder–specific studies are available, however.

Blow and colleagues (2000) and Schonfeld and colleagues (2000) found that cognitive–behavioral approaches—such as teaching older adults skills necessary to rebuild social support networks and using self–management approaches for overcoming depression, grief, and loneliness—were successful in reducing or stopping alcohol use.

Research has also found that case management services are helpful for older adults receiving alcoholism treatment and may be the best way to provide outreach services. Because traditional residential alcoholism treatment programs generally treat few older adults, small sample sizes have prevented the evaluation of formal treatment. The development of elder–specific alcoholism treatment programs in recent years has identified sufficiently large numbers of older adults with alcohol abuse or dependence disorders to begin to facilitate studies of this population (Atkinson 1995). A remaining limitation with this age group is the lack of longitudinal studies of treatment outcomes.

In one of the few long–term studies of an elder–specific specialized alcoholism treatment program, Blow and colleagues (2000) examined multidimensional 6–month outcomes for 90 patients older than age 55. At baseline, physical health functioning was similar to that reported by seriously medically ill patients (with and without alcohol problems) in other studies, whereas psychological functioning was worse. Nearly one–third of the sample had comorbid psychiatric disorders. Results suggested that the largest percentage of older adults who received elder–specific substance abuse treatment attained positive outcomes and that their conditions improved across a range of physical and psychosocial measures. Further research is needed in this area to determine the following:

• If elder female–specific specialized treatment is necessary, effective, or both
• If older women in elder–specific programs show better outcomes than older women in mixed–age programs
• If intervention and treatment approaches for alcohol and prescription drug misuse are effective with older women.

Summary

The growing population of older adults reflects the need for new, innovative prevention and intervention techniques and approaches targeted to older at–risk drinkers. These approaches should consider elder–specific characteristics such as alcohol–related symptoms and patterns of use, age of onset, and medical and mental health issues.

The range of prevention and intervention strategies available to older adults—prevention and education for people who are abstinent or low–risk drinkers, minimal advice and brief intervention for at–risk drinkers, and formal treatment for people with alcohol abuse or dependence—provides the necessary tools for health care providers to give high–quality care to older adults across the spectrum of drinking patterns.

Although some progress has been made in understanding the effectiveness of alcohol screening, brief intervention, and treatment among older women, it remains to be determined how these protocols fit into the broad spectrum of health care settings (e.g., primary care, mental health care, specialty physical health care, hospitals) and how to target specific interventions or treatments to appropriate subgroups of older women. The health care field must develop and test time– and cost–effective methods of screening, intervention, and treatment to provide optimal care to a vulnerable, growing, and under–recognized population of older women who are consuming alcohol and other drugs.

References

1. ABRAMSON, J.L.; WILLIAMS, S.A.; KRUMHOLZ, H.M.; and VACCARINO, V. Moderate alcohol consumption and risk of heart failure among older persons. JAMA: Journal of the American Medical Association 285(15):1971-1977, 2001.
2. ADAMS, W.L.; BARRY, K.L.; and FLEMING, M.F. Screening for problem drinking in older primary care patients. JAMA: Journal of the American Medical Association 276(24):1964-1967, 1996.
3. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA, 1994.
4. ATKINSON, R. Treatment programs for aging alcoholics. In: Beresford, T.P., and Gomberg, E.S.L., eds. Alcohol and Aging. New York: Oxford University Press, 1995. pp. 186-210.
5. BARRY, K.L. Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series No. 34. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1999.
6. BARRY, K.L.; OSLIN, D.; and BLOW, F.C. Prevention and Management of Alcohol Problems in Older Adults. New York: Springer Publishing, 2001.
7. BITTNER, V; SIMON, J.A.; FONG, J.; et al. Correlates of high HDL cholesterol among women with coronary heart disease. American Heart Journal 139(2):288-296, 2000.
8. BLOW, F. Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series No. 26. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1998.
9. BLOW, F.C., and BARRY, K.L. Older patients with at-risk and problem drinking patterns: New developments in brief interventions. Journal of Geriatric Psychiatry and Neurology 13(3):115-123, 2000.
10. BLOW, F.; GILLESPIE, B.W.; BARRY, K.L.; et al. "Brief screening for alcohol problems in elderly populations using the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)." Paper presented at the Research Society on Alcoholism Annual Scientific Meeting, Hilton Head Island, SC, June 20-25, 1998.
11. BLOW, F.C.; WALTON, M.A.; CHERMACK, S.T.; et al. Older adult treatment outcomes following elder-specific inpatient alcoholism treatment. Journal of Substance Abuse Treatment 19:67-75, 2000.
12. BROE, G.A.; CREASEY, H.; JORM, A.F.; et al. Health habits and risk of cognitive impairment and dementia in old age: A prospective study on the effects of exercise, smoking and alcohol consumption. Australian and New Zealand Journal of Public Health 22(5):621-623, 1998.
13. Collaborative Group on Hormonal Factors in Breast Cancer. Alcohol, tobacco and breast cancer: Collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer 87(11): 1234-1245, 2002.
14. DUFOUR, M.C., and FULLER, R.K. Alcohol in the elderly. Annual Review of Medicine 46:123-132, 1995.
15. ENSRUD, K.E.; NEVITT, M.C.; YUNIS, C.; et al. Correlates of impaired function in older women. Journal of the American Geriatrics Society 42:481-489, 1994.
16. EWING, J.A. Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association252(14):1905-1907, 1984.
17. FINLAYSON, R.E.; HURT, R.D.; DAVIS, L.J., Jr.; and MORSE, R.M. Alcoholism in elderly persons: A study of the psychiatric and psychosocial features of 216 inpatients. Mayo Clinic Proceedings 63:761-768, 1988.
18. FLEMING, M.F.; BARRY, K.L.; MANWELL, L.B.; et al. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. JAMA: Journal of the American Medical Association 277(13):1039-1045, 1997.
19. FLEMING, M.F.; MANWELL, L.B.; BARRY, K.L.; et al. Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice 48(5):378-384, 1999.
20. GAMBERT, S.R., and KATSOYANNIS, K.K. Alcohol-related medical disorders of older heavy drinkers. In: Beresford, T.P., and Gomberg, E., eds. Alcohol and Aging. New York: Oxford University Press, 1995. pp. 70-81.
21. GRAHAM, K., and SCHMIDT, G. Alcohol use and psychosocial well-being among older adults. Journal of Studies on Alcohol 60:345-351, 1999.
22. Institute of Medicine. Broadening the Base of Treatment for Alcoholism. Washington, DC: National Academy Press, 1990. pp. 242-278.
23. KLATSKY, A.L.; ARMSTRONG, M.A.; and FRIEDMAN, G.D. Red wine, white wine, liquor, beer, and risk for coronary artery disease hospitalization. American Journal of Cardiology 80(4):416-420, 1997.
24. MILLER, W.R., and ROLLNICK, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.
25. MOORE, A.A.; MORTON, S.C.; BECK, J.C.; et al. A new paradigm for alcohol use in older persons. Medical Care37(2):165-179, 1999.
26. MUKAMAL, K.J., and RIMM, E.B. Alcohol's effect on the risk of coronary heart disease. Alcohol Research & Health25(4):255-261, 2001.
27. NELSON, H.D.; NEVITT, M.C.; SCOTT, J.C.; et al. Smoking, alcohol, and neuromuscular and physical function of older women. JAMA: Journal of the American Medical Association 272:1825-1831, 1994.
28. ORGOGOZO, J.M.; DARTIGUES, J.F.; LAFONT, S.; et al. Wine consumption and dementia in the elderly: A prospective community study in the Bordeaux area. Revue Neurologique (Paris) 153(3):185-192, 1997.
29. SAUNDERS, P.A.; COPELAND, J.R.; DEWEY, M.E.; et al. Heavy drinking as a risk factor for depression and dementia in elderly men. British Journal of Psychiatry 159:213-216, 1991.
30. SCHERR, P.A.; LACROIX, A.Z.; WALLACE, R.B.; et al. Light to moderate alcohol consumption and mortality in the elderly. Journal of the American Geriatrics Society 40:651-657, 1992.
31. SCHONFELD, L.; DUPREE, L.W.; DICKSON-FUHRMANN, E.; et al. Cognitive-behavioral treatment of older veterans with substance abuse problems. Journal of Geriatric Psychiatry and Neurology 13(3):124-129, 2000.
32. SCHROTT, H.G.; BITTNER, V.; VITTINGHOFF, E.; et al. Adherence to National Cholesterol Education Program treatment goals in postmenopausal women with heart disease. The Heart and Estrogen/Progestigen Replacement Study (HERS). JAMA: Journal of the American Medical Association 277(16):1281-1286, 1997.
33. SELLERS, T.A.; VIERKANT, R.A.; CERHAN, J.R.; et al. Interaction of dietary folate intake, alcohol, and risk of hormone receptor-defined breast cancer in a prospective study of postmenopausal women. Cancer Epidemiology 11:1104-1107, 2002.
34. SIMONS, L.A.; MCCALLUM, J.; FRIEDLANDER, Y.; et al. Moderate alcohol intake is associated with survival in the elderly: The Dubbo study. Medical Journal of Australia 173(3):121-123, 2000.
35. SMITH, J.W. Medical manifestations of alcoholism in the elderly. International Journal of the Addictions 30(13 and 14):1749-1798, 1995.
36. THOMAS, V.S., and ROCKWOOD, K.J. Alcohol abuse, cognitive impairment, and mortality among older people.Journal of the American Geriatric Society 49:415-420, 2001.
37. THUN, M.J.; PETO, R.; LOPEZ, A.D.; et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. New England Journal of Medicine 337(24):1705-1714, 1997.
38. U.S. Bureau of the Census. 65+ in the United States. Current Population Reports, Special Studies, No. P23-190. Washington, DC: U.S. Government Printing Office, 1996.
39. U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed. Home and Garden Bulletin No. 232. Washington, DC: USDA, 1995.
40. VESTAL, R.E.; MCGUIRE, E.A.; TOBIN, J.D.; et al. Aging and ethanol metabolism. Clinical Pharmacology and Therapeutics 21:343-354, 1977.
41. WALLACE, P.; CUTLER, S.; and HAINES, A. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal 297(6649):663-668, 1988.

Source: National Institute on Alcohol Abuse and Alcoholism
June 2003
By Frederic C. Blow, PhD, and Kristen Lawton Barry, PhD

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Reviewed by athealth on February 8, 2014.

What is a disorder of written expression?

Students with written expression disorder have a problem with their writing skills. Their writing skills are significantly below what is normal considering the student's age, intelligence, and education. The poor writing skills cause problems with the student's academic success or other important areas of life.

What signs are associated with a disorder of written expression?

Signs associated with a disorder of written expression include:

• Written sentences and paragraphs that are inadequately formed
• Excessive spelling errors
• Excessive punctuation errors
• Excessive grammatical errors
• Extremely poor handwriting

Students who suffer from a disorder of written expression frequently have:

• Low self-esteem
• Social problems
• Increased dropout rate at school

Disorder of written expression may also be associated with:

• Conduct disorder
• ADD and ADHD
• Depression
• Other learning disorders

Does this disorder affect both males and females?

Boys are found to have the disorder much more frequently than girls.

At what age does a disorder of written expression appear?

The disorder of written expression is usually brought to the attention of the child's parents in the fourth or fifth grade when writing skills become a very important part of the classroom experience. Because of a child's immature motor skills, the diagnosis of written expression disorder is usually not made before the child is at least eight (8) years old.

How often is the disorder of written expression seen in our society?

About five percent (5%) of students in the United States are thought to have written expression disorder.

How is written expression disorder diagnosed?

The students written work contains errors including:

• spelling
• grammatics
• punctuation
• sentence and paragraph organization

They also have very poor handwriting including:

• letters of the alphabet that are reversed
• letters of the alphabet that are rotated
• letters of the alphabet that are unrecognizable
• random mixture of cursive and printed letters

Because standardized group testing is not accurate enough to diagnose this disorder, it is very important that special psychoeducational tests be individually administered to the child to determine if a learning disorder is present. Special attention must be given to the child's ethnic and cultural background by the student's examiner.

How is a disorder of written expression treated?

Although educators attempt to intervene, there is no proven effective treatment for the disorder of written expression. Emphasis on the remedial teaching of writing and a heavy emphasis on student practice of writing may be helpful.

What happens to someone with a disorder of written expression?

With or without treatment, the disorder of written expression will gradually improve. However, even when good help is available, the student tends to have chronic problems with writing skills.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Developed by John L. Miller, MD
Page last modified or reviewed on January 24, 2014

Mental Disorders in America

Mental disorders are common in the United States and internationally. An estimated 26.2 percent of Americans ages 18 and older - about one in four adults - suffer from a diagnosable mental disorder in a given year.¹ When applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure translates to 57.7 million people.² Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion - about 6 percent, or 1 in 17 - who suffer from a serious mental illness.¹ In addition, mental disorders are the leading cause of disability in the U.S. and Canada.³ Many people suffer from more than one mental disorder at a given time. Nearly half (45 percent) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity.¹

In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).⁴

Mood Disorders

Mood disorders include major depressive disorder, dysthymic disorder, and bipolar disorder.

• Approximately 20.9 million American adults, or about 9.5 percent of the U.S. population age 18 and older in a given year, have a mood disorder.^1,2
• The median age of onset for mood disorders is 30 years.⁵
• Depressive disorders often co-occur with anxiety disorders and substance abuse.⁵

Major Depressive Disorder

• Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44.³
• Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.^1,2
• While major depressive disorder can develop at any age, the median age at onset is 32.⁵
• Major depressive disorder is more prevalent in women than in men.⁶

Dysthymic Disorder

• Symptoms of dysthymic disorder (chronic, mild depression) must persist for at least two years in adults (one year in children) to meet criteria for the diagnosis. Dysthymic disorder affects approximately 1.5 percent of the U.S. population age 18 and older in a given year.¹ This figure translates to about 3.3 million American adults.²
• The median age of onset of dysthymic disorder is 31.¹

Bipolar Disorder

• Bipolar disorder affects approximately 5.7 million American adults, or about 2.6 percent of the U.S. population age 18 and older in a given year.^1,2
• The median age of onset for bipolar disorders is 25 years.⁵

Suicide

• In 2006, 33,300 (approximately 11 per 100,000) people died by suicide in the U.S.⁷
• More than 90 percent of people who kill themselves have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder.⁸
• The highest suicide rates in the U.S. are found in white men over age 85.⁹
• Four times as many men as women die by suicide⁹; however, women attempt suicide two to three times as often as men.¹⁰

Schizophrenia

• Approximately 2.4 million American adults, or about 1.1 percent of the population age 18 and older in a given year,¹¹ have schizophrenia.
• Schizophrenia affects men and women with equal frequency.¹²
• Schizophrenia often first appears in men in their late teens or early twenties. In contrast, women are generally affected in their twenties or early thirties.¹²

Anxiety Disorders

Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias (social phobia, agoraphobia, and specific phobia).

• Approximately 40 million American adults ages 18 and older, or about 18.1 percent of people in this age group in a given year, have an anxiety disorder.^1,2
• Anxiety disorders frequently co-occur with depressive disorders or substance abuse.¹
• Most people with one anxiety disorder also have another anxiety disorder. Nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.5 ⁵

Panic Disorder

• Approximately 6 million American adults ages 18 and older, or about 2.7 percent of people in this age group in a given year, have panic disorder.^1,2
• Panic disorder typically develops in early adulthood (median age of onset is 24), but the age of onset extends throughout adulthood.⁵
• About one in three people with panic disorder develops agoraphobia, a condition in which the individual becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack.¹²

Obsessive-Compulsive Disorder (OCD)

• Approximately 2.2 million American adults age 18 and older, or about 1.0 percent of people in this age group in a given year, have OCD.^1,2
• The first symptoms of OCD often begin during childhood or adolescence, however, the median age of onset is 19.⁵

Post-Traumatic Stress Disorder (PTSD)

• Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD.^1,2
• PTSD can develop at any age, including childhood, but research shows that the median age of onset is 23 years.⁵
• About 19 percent of Vietnam veterans experienced PTSD at some point after the war.¹³ The disorder also frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; terrorism; natural or human-caused disasters; and accidents.

Generalized Anxiety Disorder (GAD)

• Approximately 6.8 million American adults, or about 3.1 percent of people age 18 and over, have GAD in a given year.^1,2
• GAD can begin across the life cycle, though the median age of onset is 31 years old.⁵

Social Phobia

• Approximately 15 million American adults age 18 and over, or about 6.8 percent of people in this age group in a given year, have social phobia.^1,2
• Social phobia begins in childhood or adolescence, typically around 13 years of age.⁵

Agoraphobia

Agoraphobia involves intense fear and anxiety of any place or situation where escape might be difficult, leading to avoidance of situations such as being alone outside of the home; traveling in a car, bus, or airplane; or being in a crowded area.⁵

• Approximately 1.8 million American adults age 18 and over, or about 0.8 percent of people in this age group in a given year, have agoraphobia without a history of panic disorder.^1,2
• The median age of onset of agoraphobia is 20 years of age.⁵

Specific Phobia

Specific phobia involves marked and persistent fear and avoidance of a specific object or situation.

• Approximately 19.2 million American adults age 18 and over, or about 8.7 percent of people in this age group in a given year, have some type of specific phobia.^1,2
• Specific phobia typically begins in childhood; the median age of onset is seven years.⁵

Eating Disorders

The three main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder.

• In their lifetime, an estimated 0.6 percent of the adult population in the U.S. will suffer from anorexia, 1.0 percent from bulimia, and 2.8 percent from a binge eating disorder. ¹⁴
• Women are much more likely than males to develop an eating disorder. They are three times as likely to experience anorexia (0.9 percent of women vs. 0.3 percent of men) and bulimia (1.5 percent of women vs. 0.5 percent of men) during their life. They are also 75 percent more likely to have a binge eating disorder (3.5 percent of women vs. 2.0 percent of men).¹⁴
• The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population.¹⁵

Attention Deficit Hyperactivity Disorder (ADHD)

• ADHD, one of the most common mental disorders in children and adolescents, also affects an estimated 4.1 percent of adults, ages 18-44, in a given year.¹
• ADHD usually becomes evident in preschool or early elementary years. The median age of onset of ADHD is seven years, although the disorder can persist into adolescence and occasionally into adulthood.⁵

Autism

Autism is part of a group of disorders called autism spectrum disorders (ASDs), also known as pervasive developmental disorders. ASDs range in severity, with autism being the most debilitating form while other disorders, such as Asperger syndrome, produce milder symptoms.

• Estimating the prevalence of autism is difficult and controversial due to differences in the ways that cases are identified and defined, differences in study methods, and changes in diagnostic criteria. A recent study by the Centers for Disease Control and Prevention (CDC) reported the prevalence of autism among 8 year-olds to be about 1 in 110.¹⁶
• Autism and other ASDs develop in childhood and generally are diagnosed by age three.¹⁷
• Autism is about four times more common in boys than girls. Girls with the disorder, however, tend to have more severe symptoms and greater cognitive impairment.^16,17

Personality Disorders

• Personality disorders represent an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it.⁴ These patterns tend to be fixed and consistent across situations and are typically perceived to be appropriate by the individual even though they may markedly affect their day-to-day life in negative ways. Among American adults ages 18 and over, an estimated 9.1% have a diagnosable personality disorder.¹⁸
• Antisocial Personality Disorder - Antisocial personality disorder is characterized by an individual's disregard for social rules and cultural norms, impulsive behavior, and indifference to the rights and feelings of others. Approximately 1.0 percent of people aged 18 or over have antisocial personality disorder.¹⁸
• Avoidant Personality Disorder - Avoidant personality disorder is characterized by extreme social inhibition, sensitivity to negative evaluation, and feelings of inadequacy. Individuals with avoidant personality disorder frequently avoid social interaction for fear of being ridiculed, humiliated, or disliked. An estimated 5.2 percent of people age 18 or older have an avoidant personality disorder.¹⁸
• Borderline Personality Disorder - Borderline Personality Disorder (BPD) is defined by the DSM-IV as a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts. Approximately 1.6 percent of Americans age 18 or older have BPD.¹⁸

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
3. The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. Geneva, Switzerland: WHO, 2008. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_AnnexA.pdf.
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6. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 2003; Jun 18;289(23):3095-105.
7. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) : www.cdc.gov/ncipc/wisqars accessed April 2010.
8. Conwell Y, Brent D. Suicide and aging I: patterns of psychiatric diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.
9. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports. 2004 Oct 12;53 (5):1-115.
10. Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.
11. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993 Feb;50(2):85-94.
12. Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
13. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koen KC, Marshall R. The psychological risk of Vietnam for U.S. veterans: A revist with new data and methods. Science. 2006; 313(5789):979-982.
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NIH Publication No. 06-4584
Updated/Reviewed: July 23, 2010

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Reviewed by athealth on February 8, 2014.

by Alan Siegel, PhD

Our children do not have to suffer their nightmares in silence, brooding about the lingering feeling of suffocation left by the formless ghost or shuddering at the memory of the razor-sharp teeth of a pack of wolves ripping into their flesh. There are remedies for even the most dreadful nightmares.

Unfortunately, the raw terror that lingers after a nightmare may accentuate a child's insecurity and bring on anxiety for hours or even days afterward. It may even disturb their ability to sleep by inducing insomnia, or fears and phobias about sleeping and dreaming. To help your child restore their capacity to sleep and to harness the healing and creative potential of scary dreams, we must help them break the spell of their nightmares.

The silver lining of painful nightmares is that through the often-transparent symbolism, they shine a spotlight on the issues that are most the upsetting, yet inexpressible for your child. Every nightmare, no matter how distressing, contains vital information about crucial emotional challenges in your child's life. To a parent whose ears and heart are open, listening to the most distressing nightmares is like hearing your child's unconscious, speaking directly to you delivering a special call for help.

Most nightmares are a normal part of coping with changes in our lives. They are not necessarily a sign of pathology and may even be a positive indication that we are actively coping with a new challenge. For children, this could occur in response to such events as entering school, moving to a new neighborhood or living through a divorce or remarriage.

Using role-playing and fantasy rehearsals, parents can coach their children to assert their magical powers and tame the frights of the night. New endings for dreams can be created so that falling dreams become floating dreams and chase dreams end with the capture of the villain. When we give our children reassurance and encouragement to explore creative solutions to dream dilemmas, we restore their ability to play with the images in their nightmares rather than feeling threatened or demoralized. These assertiveness skills carry over into future dream confrontations and lead to greater confidence to face waking challenges.

Sophia's Spider Dream

Even very young children can learn to encounter and overcome the threatening creatures of their nightmares. My daughter, Sophia, mentioned her first dream just before she turned two. She woke from a nap one day and spontaneously said "bird fly outside" while motioning towards the window with her hands. Because Sophia had always been fascinated with the flight and sounds of birds and airplanes, my wife and I weren't sure if it was really a dream or just a fantasy. However, a month later, Sophia woke up screaming and sobbing with a bona fide nightmare about spiders.

The Attack of the Dream Spider

'Pider on Sophia...off Sophia's leg...Dad, no more 'pider please!"

While holding Sophia and comforting her, she continued to sob, saying, "Sophia scared". I reassured her that "Daddy will protect you from spiders". I am going to teach you how to get those bad spiders away from Sophia" She listened with wide eyes. "When you see those spiders, tell them Go away bad spiders. Get out of Sophia's bed and don't come back!" I emphatically repeated this anti-spider anthem three times. Suddenly Sophia smiled a slightly mischievous smile. "Go away 'piders" She said tentatively. She repeated it twice and smiled waving her hands as if to motion the spiders away. She was significantly calmed and after a bit of rocking and a short story, she fell back to sleep easily.

When Sophia woke the next morning, I asked her "Did you have any more dreams?" She flashed a playful smile and said "piders!" and laughed. For two more days, she grinned and said 'piders' when she woke. These subsequent dream reports were probably fabricated judging by the mischievous look on her face. However, within a few days she began to report other dreams, mostly animals, some threatening and some friendly.

Sophia's dream spiders were more terrifying than anything in waking reality. I took the dream spiders seriously by talking directly to them and offering Sophia reassurance (both physical and emotional), a concrete strategy for facing the dream creatures and follow-up to reinforce her ability to break the spell of the attacking dream spiders.

Children's Nightmares

Children suffer more frequent nightmares than their parents and, prior to the age of six, nightmares are especially common. As soon as your child can speak, he or she may wake with a one or two word tale of a wolf or ghost. There is even speculation among specialists in child development that the sleep disturbances of infants in the first year of life may be wordless nightmares.

Nightmares diminish as children grow older, master their fears, and gain more control over their world. A long-term study of 252 children showed that five to ten percent of seven- and eight-year-old children had nightmares once a week. By the time children in the study were between eleven and fourteen, disturbing dreams were infrequent, especially for boys.¹

Most nightmares are a normal part of coping with changes in our lives. They are not necessarily a sign of pathology and may even be a positive indication that we are actively coping with a new challenge. For children, this could occur in response to such events as entering school, moving to a new neighborhood or living through a divorce or remarriage.

A good working assumption is that many nightmares in children are reactions to upsetting events, situations and relationships. It is important to keep in mind that often a stress such as moving to a new neighborhood will be complicated by a chain reaction of other changes. Nightmares will usually diminish in intensity and frequency as the child and the family recover and cope with stresses such as a death in the family or birth of a new family member.

Eight-year-old Brian and his younger brother Jake were not only moving from the house they had always lived in, they were changing schools and saying good-bye to school friends. After the last day at his old school, Brian's family moved into his friend Colin's house for the summer while Colin's family went on vacation. On the first night of sleeping in his friend's room, Brian had a dreadful nightmare.

In tears, Brian woke and came running into his parent's room, lamenting his bad dream. "I can't stop thinking about the awful smell". Brian's mother, Gina, gave him a sympathetic hug and invited him to sit down and tell the whole dream. Sobbing slightly, Brian blurted out what he could remember.

Poison Gas

I see my friends Colin and his brother Ross opening the door and going into a dark room like the room I am staying in. I keep waiting over 1/2 hour but they don't come out. Finally, I decide to go in and check on them. I smell gas and think it might be poison gas. Suddenly I see them lying dead on floor.

Seeing Brian's distress, Gina wanted to reassure him. "If someone is dead in a dream, does it mean they are really gonna die?" " No, Brian, things that we dream about are important but they don't usually come true when we are awake. Possibly this dream isn't about people dying but about missing your friends after we move." "Yeah but it was so gross seeing them dead and the gas made me feel like I was gonna get poisoned too". Gina responded "That must have been a horrible sight. I would have been scared too if I had that dream."

After a moment of pondering, Brian relaxed a bit and said "that room I am staying in does smell kinda stinky." He had complained before bed that his friend Colin's collection of old teddy bears smelled bad. Gina agreed and taking the dream at face value, she suggested that they spray some air freshener before he goes back to sleep. As she looked in the cabinets for the freshener, Gina realized that Brian's dream went beyond a simple reaction to the foul smell of the stuffed animals. She realized that she and her husband had been so busy packing and preparing for the move, they hadn't had time to really talk with Brian about his sense of loss and his fears of the unknown.

Brian's morbid nightmare helped his mother understand his emotional needs. As a result of the dream, Gina spent more time talking about the move with Brian and his brother. The family took steps to keep connections with old friends, and visited their new school during the summer to make it more familiar. While in their temporary house, they also moved the smelly bears and deodorized the room.

The poison gas was a response not only to the actual bad smell in the room in which Brian was staying but also symbolized the dangerous sense of insecurity Brian felt, moving from a familiar home and school and friends to an unfamiliar and unpleasant situation. If death or grief is not a current issue in the dreamer's life, death dreams frequently symbolize loss or painful changes. For Brian, the dark room that swallowed up his friends and killed them expressed his multiple losses as well as fear.

During a period of stress or family crisis, parents should expect more frequent nightmares. Likewise, when a child suddenly has an increase in nightmares, they are letting you know they are feeling overwhelmed and insecure. You don't have to interpret or explain their nightmares. Your reassurance and empathy plus some hugs are the first step towards helping them restore their emotional balance.

Recurring Nightmares

Anyone who keeps track of their dreams and nightmares will begin to notice recurring symbols and patterns. Studies of people who have kept dream journals for as long as 50 years have shown that certain animals or houses or people who appear in a person's childhood or teenage dreams will still turn up when their hair is gray.

Your own personal repertoire of nightmare symbols may emerge early in childhood, evolving and transforming throughout your life span. After being stung by a bee when she was three, Annie began to have repetitive dreams of being chased and bitten by bees and other bugs. While her parents initially assumed that the bee sting experience was still bothering her, they began to notice that Annie would get stung in her dreams when other things would upset her; when her Mom went on a business trip, when she temporarily lost her favorite doll, and just after her brother was born. Her bee sting dreams had become symbolic of events that threatened her security.

Through repeating dream patterns, such as Annie's bee sting dreams, by earlier traumatic events, they are later stimulated by current stressful situations. Repeating dream patterns may also be influenced by disturbing images from television and film (no one wants a Freddie Kreuger dream), family fears, cultural stereotypes, myths, and religious beliefs and stories.

What can we learn from recurrent dreams? They are often a warning of lingering psychological conflicts. For example, children of divorce frequently dream that their parents have reunited; abuse survivors are often victims or perpetrators of violence in their dreams; and adopted children intermittently dream of their birth parents.

Conversely, changes within recurring dreams may signal the onset of resolving a psychological impasse. For example, a survivor of child abuse who was making a therapeutic breakthrough in her emotional recovery dreamed of triumphing over a shadowy, hostile figure that had threatened and chased her in innumerable prior nightmares.

Stages of Resolution in Recurring Dreams

Three stages of resolution can be identified in children's nightmares.

• Threat: In the dream, a main character is threatened and unable to mount any defense. For example, he or she may be paralyzed while trying to flee the jaws of a hungry ghost imprisoned by aliens.
• Struggle: Attempts to confront the nightmare adversary are partially successful in fending off danger. An example would be temporarily escaping a robber with a knife and trying to dial the phone for help.
• Resolution: The nightmare enemy, opponent, or oppressor is vanquished and the threatening creatures are put in cages, slain, or held at bay with magic wands, or otherwise disarmed.

In some cases, children spontaneously resolve a recurring nightmare as the formerly distressing situations which caused the nightmares get worked out in the child's real life. Bob had one such persistent childhood nightmare that changed decisively with time. Although his father was not inherently cruel and abusive, his stormy personality often led to outbursts of anger that frightened Bob and his sister.

After his father's return from military service, Bob began having nightmares about horrific encounters with a ghost-like monster in the basement of his house. These ghost nightmares continued for almost two years from when he was seven until he was nine.

At first the ghost dreams would leave him shaking in abject terror. As time went by he would try to stand up to the ghost but as the following dream indicates, he did not immediately prevail.

Screaming at the Ghost in the Basement

I was down in the basement in bed sleeping and it was the terror of all terrors. I knew the ghost was around the corner to the right between me and these stairways where you could get back up to the house. I knew if I moved or made the slightest sound the ghost would get me. I couldn't stand the tension so I finally decided I would just yell and let the ghost come out and get me. I sat up in bed and screamed as loud as I could. The ghost came roaring out of its hiding place and jumped all over me and attacked me and I instantly woke up.

Bob woke up feeling simultaneously scared and defiant. Despite the consequences, he was determined to fight back. He later interpreted the threatening ghost as a symbol of his father's angry outbursts.

When his father had returned from overseas, he had not only interfered with Bob's special relationship with his mother, but had been punitive with Bob as he tried to reassert his role as "man of the house." Gradually, as Bob adjusted to his father's presence, he became less intimidated by his father's moods and began to identify with the positive characteristics of his father -- especially his father's creativity with tools and building.

Bob's gradually improving relationship with his father was reflected in a breakthrough dream.

Dad Helps Me Float to Safety

I was at the top of the basement stairs looking down. The stairs disappeared from under me and I was falling and falling into the basement, terrified the ghost would get me when I hit the floor. Just then I saw my dad down there. He turned on this blue light and as soon as he did I floated into the basement and knew that I was safe.

Bob's father who had been verbally harsh during the months after returning from overseas had begun to soften and allow Bob to work with him in his workshop which, happened to be in the basement. Providing the blue light symbolized how his father had transformed from a competitor for Bob's mother's love into a positive paternal role model and protector. That positive change in the father/son relationship allowed Bob to work out his recurrent nightmare.

A crucial factor in understanding repetitive dreams is looking at the degree of resolution or mastery in the dream. As children mature emotionally and intellectually, they gain increasing control over their childhood fears and feel more confident in their ability to solve problems and handle situations independently. This gradually increasing sense of control is reflected not only in their waking achievements but in their dream life.

The Four R's That Spell Nightmare Relief

There are many potentially beneficial nightmare remedies that parents, family members, and even siblings can use to help a child break the spell of a disturbing nightmare and transform terror into creative breakthroughs. In order to soothe the lingering terror and banish the demons of the night, you must learn the Four R's that spell nightmare relief for your children. They are Reassurance, Rescripting, Rehearsal, and Resolution.

Reassurance is the first and most important dimension of remedying children's nightmares. This includes "welcoming the dream" with special emphasis on physical and emotional reassurance, which will calm your child's anxiety and help them feel safe enough to give details about the nightmare and be open to further exploration.

Everyone has nightmares and no one has to bear the pain without help. Reassurance quells the post-nightmare jitters and allows you and your child an opportunity to discover both the creative possibilities and the source of what sparked the nightmare that may still be disturbing your child.

Rescripting means inviting and guiding your child to imagine changes in the outcome of their dream by reenacting or rewriting the plot. Even with young children, rescripting is most effective when it is a collaborative process of brainstorming together. The most well known form of rescripting is creating one or more new endings for a dream using art work, fantasy, drama, and writing.

Rescripting² is like assertiveness training for the imagination. Ominous dream monsters, demons, and werewolves can be tricked and trapped, tamed and leashed, given time-outs, bossed around, and generally made less intimidating. With parental assistance, the child with nightmares can be taught to revolt and throw off the yoke of dream oppression by using magical means such as fairy dust, a wizard's wand, Star Trek™ "Phasers," special incantations and spells, or other handy tools of the imagination. Very often developing and rehearsing solutions to dream dilemmas carries over to increased confidence in facing waking conflicts.

One of the most enjoyable aspects of resolving nightmares is helping your child create their own repertoire of "Magical Tools" for dream assertiveness. These tools are limited only by your imagination and can be inspired by your child's interests, current movies or television shows, your families cultural background, books or projects they are completing for school, and so on. Just as garlic or a crucifix repels a werewolf or a silver bullet kills a vampire, some magical tools can be chosen to disarm a specific character in a recurring nightmare such as a special spray for ghosts or an invisible shield for gunmen. Other tools can be of the all-purpose variety such as the old reliable magic wand, Luke Skywalker's "force" from Star Wars or even trusty police tools such as handcuffs or a secure jail cell with the key thrown away!

Zoe, at age six, had occasional, recurrent nightmares of fire ever since she witnessed the Oakland/Berkeley Firestorm³ when she was two years old. The following dream was one of the worst episodes of this theme.

The Killing Fire

I was at my school and about six people came and set fire to the whole school and it burned all the way to the Golden Gate Bridge and they were going to kill all the kids and they only chose to save my sister.

She woke from the dream in the middle of the night, tearfully pleading for hugs and reassurance. She did not feel comfortable or ready to talk about the nightmare at the time or even in the morning before school. Because of her artistic inclination, she was, however, intrigued with the idea of drawing her fire dream that evening and ended up making a series of sketches with markers.

By talking about the elements of her drawing, the bright colors, the architecture of her school, and placement of the Golden Gate Bridge, Zoe was able to begin exploring the dream through the medium of her sketches. This led her to recall some of her earlier fire dreams and to ask a series of questions about the Firestorm--how it had started and where she was during the event. She decided she wanted to actually see the site of the fire, which was located quite near some friends of the family. At the time of the visit, many houses had been rebuilt, but she was fascinated by the fact that there were still empty lots and burned out foundations where homes had been destroyed.

Like many children her age and older, Zoe did not want to discuss other fears connected to her recent fire dream except to say that she had the dream after watching a violent movie at a friend's house. Although she may have had other worries at the time of the nightmare, her desire not to explore further was respected by her parents. However her artistic rendition of the dream, curious questions, and resulting visit to the fire zone resolved her fire nightmares. Subsequent to her creative exploration of this nightmare, she gradually became more forthcoming in reporting upsetting dreams and even offering ideas about what caused them based on the previous day's events.

Even chronic nightmare sufferers, both adults and children, have found relief from relatively simple treatments and techniques. Vietnam veterans with persistent nightmares have been successfully treated with psychotherapy approaches that focus on resolving both the dreams and the unresolved traumas that caused the dreams to continue.

There are a few areas of caution that should be considered with respect to rescripting. The first is the use of violence in fantasy solutions to bad dreams. Killing the nightmare adversary may not be the optimal solution even in imaginary battles. Ann Sayre Wiseman, author of Nightmare Help warns that suggesting the murder or destruction of a dream foe may subtly encourage violent solutions to life problems and reinforce a tendency that children are already overexposed to through television, movies, news and violence in our society. On the other hand, encouraging creative, nonviolent, assertion in working out dream battles, may lead to improved and more constructive waking problem-solving skills.

The second caution is about the limits of creating new endings for nightmares. There is a misconception that using fantasy and magical tools to create a new dream ending assures that the underlying problem that stimulated the dream has been resolved. This may not be the case. While impressive results have been obtained using rescripting to reduce the frequency and intensity of nightmares, we must remember that nightmares, especially recurring ones, are messages--even warnings--from within that we are overwhelmed by a new situation, crisis, or chronic conflict such as a custody dispute or marital conflict. When there is a persistent problem in a child's life, we may need to go beyond reassurance and rescripting to discover fundamental solutions to the life problems that set off the dream. This leads us to the two final R's - rehearsal and resolution.

Rehearsal is practicing solutions to a nightmare's various threats. Going a step beyond the new endings or magical tools used in rescripting a nightmare, rehearsal involves repeating the dream and its solutions in various forms until a sense of mastery or accomplishment has been achieved. This stage parallels the stage of psychotherapy called "working through," where for adults, the insights they have gained need to be put to the test--at first in the relationship with their therapist and gradually by practicing new forms of relating with others and experiencing themselves in new ways.

Resolution is the final stage of alleviating the haunting spell of a nightmare. Discovering the source of the nightmare in your child's life and working towards acknowledging and even correcting the life problem that has caused the nightmares are preliminary steps. Resolution can only come after a child feels secure enough (reassurance) to explore new solutions through art, writing, drama, and discussion (rescripting) and has practiced those solutions (rehearsal) with a parent or adult guide.

If a child continues to be curious about what is emerging from his or her exploration of a dream, they can be encouraged to honor their dream by connecting it to a person, situation, or feeling in their current life. By keeping in mind the major emotional issues affecting your child such, as the birth of a sibling or starting at a new school, parents can be alerted to the probable sources of a nightmare.

Through the process of exploring, brainstorming, and rehearsing metaphoric solutions to their children's nightmares, parents begin to feel more secure in linking dream symbols to the current events and relationships in their child's waking world. Nightmares emphasize to parents exactly what is most difficult for their child and open up possibilities for resolving important emotional challenges.

When To Seek Help for Nightmares

Whereas moderate nightmare activity may be a potentially healthy sign that the unconscious mind is actively coping with stress and change, frequent nightmares indicate unresolved conflicts that are overwhelming your child. When children's nightmares persist, when their content is consistently violent or disturbing, and when the upsetting conflicts in the dreams never seem to change or even achieve partial resolution, it may be time to seek further help from a mental health specialist or pediatrician. Especially if there is no obvious stress in your child's life, repetitive nightmares could also be caused by a reaction to drugs or a physical condition, so it is advisable to consult a physician to rule out medical causes when nightmares do not appear to have a psychological origin.

Repetitive nightmares are often accompanied by other symptoms especially fears of going to sleep, anxieties or phobias. Increased nightmares can usually be linked to a recognizable stress in the child's life such as absence or loss of a parent, suffering abuse or violence, marital or custody disputes in the family, social or academic difficulties at school, such as being teased or having an undiagnosed learning or attention problem.

Nightmares are more often like a vaccine than a poison. A vaccination infects us with a minute dose of a disease that mobilizes our antibodies and makes us more resistant to the virulence of smallpox or polio. As distressing as nightmares can be, they offer powerful information about issues that are distressing your child. When children share their nightmares and receive reassurance from their parents, they feel the emotional sting of the dream, but also begin the process of strengthening their psychological defenses and facing their fears with more resilience. Gradually, a parent's empathic response to their child's nightmares can break the cycle of bad dreams and transform intensely negative experiences into triumphs of assertiveness and collaborative family problem solving.

The above excerpt was reprinted with permission from Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares by Alan Siegel and Kelly Bulkeley. Published by Random House's Three Rivers Press. Copyright © 1998.

Notes

1. Ernest Hartmann, 1991.
2. The concept of "rescripting" was adapted from Gordon Halliday, "Treating Nightmares in Children" in Charles Schaeffer, (editor) Clinical Handbook of Sleep Disorders in Children (New York, Jason Aronson, 1995)
3. Alan Siegel, "The Dreams of Firestorm Survivors", in Barrett, Deirdre (editor), Trauma and Dreams, (Boston: Harvard University Press, 1996).

Reprinted with permission from Alan Siegel, PhD

For additional articles on sleep and dreams, click on http://www.asdreams.org/magazine/articles/index.htm

Reviewed by athealth on February 6, 2014.

What is the prevalence of overweight and obesity among U.S. adults?

Results of the National Health and Nutrition Examination Survey for 1999-2002 indicate that the following percentages of U.S. adults are overweight or obese:

• An estimated 30 percent of U.S. adults aged 20 years and older - over 60 million people - are obese, defined as having a body mass index (BMI) of 30 or higher.
• An estimated 65 percent of U.S. adults aged 20 years and older are either overweight or obese, defined as having a BMI of 25 or higher.

What is the prevalence of overweight among U.S. children?

Results of the National Health and Nutrition Examination Survey for 1999-2002 indicate that an estimated 16 percent of children and adolescents ages 6-19 years are overweight. For children, overweight is defined as a body mass index (BMI) at or above the 95th percentile of the CDC growth charts for age and gender.

What is the difference between being overweight and being obese?

Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered healthy for a given height. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.

For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI).

• An adult who has a BMI between 25 and 29.9 is considered overweight. A
• n adult who has a BMI of 30 or higher is considered obese.

See the following table for an example.

Height	Weight Range	BMI	Considered
5' 9"	124 lbs or less	Below 18.5	Underweight
	125 lbs to 168 lbs	18.5 to 24.9	Healthy weight
	169 lbs to 202 lbs	25.0 to 29.9	Overweight
	203 lbs or more	30 or higher	Obese

It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight even though they do not have excess body fat. For more information about BMI, visit Body Mass Index.

For children and teens, BMI ranges above a normal weight have different labels (at risk of overweight and overweight). Additionally, BMI ranges for children and teens are defined so that they take into account normal differences in body fat between boys and girls and differences in body fat at various ages. For more information about BMI for children and teens (also called BMI-for-age), visit BMI for Children and Teens.

What are some of the factors that contribute to overweight and obesity?

Researchers have found that several factors can contribute to the likelihood of someone's becoming overweight or obese.

• Behaviors. What people eat and their level of physical activity help determine whether they will gain weight. A number of factors can influence diet and physical activity, including personal characteristics of the individual, the individual's environment, cultural attitudes, and financial situation.
• Genetics. Heredity plays a large role in determining how susceptible people are to becoming overweight or obese. Genes can influence how the body burns calories for energy and how the body stores fat.

How does being overweight or obese affect a person's health?

When people are or overweight or obese, they are more likely to develop health problems such as the following:

• Hypertension
• Dyslipidemia (for example, high total cholesterol or high levels of triglycerides)
• Type 2 diabetes
• Coronary heart disease
• Stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea and respiratory problems
• Some cancers (endometrial, breast, and colon)

The more overweight a person is, the more likely that person is to have health problems. Among people who are overweight and obese, weight loss can help reduce the chances of developing these health problems. Studies show that if a person is overweight or obese, reducing body weight by 5 percent to 10 percent can improve one's health.

What can be done about this major public health problem?

The Surgeon General has called for a broad approach to help prevent and reduce obesity. The Surgeon General has identified 15 activities as national priorities.

What are the costs associated with overweight and obesity?

According to The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity, the cost of obesity in the United States in 2000 was more than $117 billion ($61 billion direct and $56 billion indirect).

What is being done by CDC to address the problem of overweight and obesity?

CDC and its partners work in a variety of ways to prevent and control obesity. A few examples of these efforts include:

• CDC funds a number of programs in state health departments, communities, and schools. For example, CDC's Division of Nutrition and Physical Activity funds state health department programs to help develop and carry out targeted nutrition and physical activity interventions to prevent obesity and other chronic diseases. CDC also provides consultation, technical assistance, and training to use programs.
• CDC funds other programs which have physical activity, nutrition, and obesity components, such as STEPS to a HealthierUS and Coordinated School Health Programs.
• CDC monitors weight status or related behaviors, such as diet and physical activity. These efforts include the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), Pediatric Nutrition Surveillance System (PedNSS), and Youth Risk Behavior Surveillance System (YRBSS).
• CDC funds and conducts research on the individual and environmental factors that determine weight status and related health effects, on strategies and interventions to change weight or weight-related behaviors, and on the economic impact of overweight and obesity.
• CDC provides growth charts that are used to identify weight problems among young people and provides training on the use of those charts.

What are some suggestions for losing weight?

Most experts recommend that someone attempting to lose a large amount of weight consult with a personal physician or health care professional before beginning a weight-loss program. The Surgeon General's Healthy Weight Advice for Consumers makes the following general recommendations:

• Aim for a healthy weight. People who need to lose weight should do so gradually, at a rate of one-half to two pounds per week.
• Be active. The safest and most effective way to lose weight is to reduce calories and increase physical activity.
• Eat well. Select sensible portion sizes and follow the Dietary Guidelines for Americans.

How can physical activity help prevent overweight and obesity?

Physical activity, along with a healthy diet, plays an important role in the prevention of overweight and obesity (USDHHS, 2001). In order to maintain a stable weight, a person needs to expend the same amount of calories as he or she consumes.

Although the body burns calories for everyday functions such as breathing, digestion, and routine daily activities, many people consume more calories than they need for these functions each day. A good way to burn off extra calories and prevent weight gain is to engage in regular physical activity beyond routine activities.

The Dietary Guidelines for Americans 2005 offers the following example of the balance between consuming and using calories:

If you eat 100 more food calories a day than you burn, you'll gain about 1 pound in a month. That's about 10 pounds in a year. The bottom line is that to lose weight, it's important to reduce calories and increase physical activity.

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Nutrition and Physical Activity
Last Reviewed: 09/29/2006

Reviewed by athealth on February 6, 2014.

Developmental psychologists have been interested in how parents influence the development of children's social and instrumental competence since at least the 1920s. One of the most robust approaches to this area is the study of what has been called "parenting style." This Digest defines parenting style, explores four types, and discusses the consequences of the different styles for children.

Parenting Style Defined

Parenting is a complex activity that includes many specific behaviors that work individually and together to influence child outcomes. Although specific parenting behaviors, such as spanking or reading aloud, may influence child development, looking at any specific behavior in isolation may be misleading. Many writers have noted that specific parenting practices are less important in predicting child well-being than is the broad pattern of parenting. Most researchers who attempt to describe this broad parental milieu rely on Diana Baumrind's concept of parenting style. The construct of parenting style is used to capture normal variations in parents' attempts to control and socialize their children (Baumrind, 1991). Two points are critical in understanding this definition. First, parenting style is meant to describe normal variations in parenting. In other words, the parenting style typology Baumrind developed should not be understood to include deviant parenting, such as might be observed in abusive or neglectful homes. Second, Baumrind assumes that normal parenting revolves around issues of control. Although parents may differ in how they try to control or socialize their children and the extent to which they do so, it is assumed that the primary role of all parents is to influence, teach, and control their children.

Parenting style captures two important elements of parenting: parental responsiveness and parental demandingness (Maccoby & Martin, 1983). Parental responsiveness (also referred to as parental warmth or supportiveness) refers to "the extent to which parents intentionally foster individuality, self-regulation, and self-assertion by being attuned, supportive, and acquiescent to children's special needs and demands" (Baumrind, 1991, p. 62). Parental demandingness (also referred to as behavioral control) refers to "the claims parents make on children to become integrated into the family whole, by their maturity demands, supervision, disciplinary efforts and willingness to confront the child who disobeys" (Baumrind, 1991, pp. 61-62).

Four Parenting Styles

Categorizing parents according to whether they are high or low on parental demandingness and responsiveness creates a typology of four parenting styles: indulgent, authoritarian, authoritative, and uninvolved (Maccoby & Martin, 1983). Each of these parenting styles reflects different naturally occurring patterns of parental values, practices, and behaviors (Baumrind, 1991) and a distinct balance of responsiveness and demandingness.

1. Indulgent parents (also referred to as "permissive" or "nondirective") "are more responsive than they are demanding. They are nontraditional and lenient, do not require mature behavior, allow considerable self-regulation, and avoid confrontation" (Baumrind, 1991, p. 62). Indulgent parents may be further divided into two types: democratic parents, who, though lenient, are more conscientious, engaged, and committed to the child, and nondirective parents.
2. Authoritarian parents are highly demanding and directive, but not responsive. "They are obedience- and status-oriented, and expect their orders to be obeyed without explanation" (Baumrind, 1991, p. 62). These parents provide well-ordered and structured environments with clearly stated rules. Authoritarian parents can be divided into two types: nonauthoritarian-directive, who are directive, but not intrusive or autocratic in their use of power, and authoritarian-directive, who are highly intrusive.
3. Authoritative parents are both demanding and responsive. "They monitor and impart clear standards for their children's conduct. They are assertive, but not intrusive and restrictive. Their disciplinary methods are supportive, rather than punitive. They want their children to be assertive as well as socially responsible, and self-regulated as well as cooperative" (Baumrind, 1991, p. 62).
4. Uninvolved parents are low in both responsiveness and demandingness. In extreme cases, this parenting style might encompass both rejecting-neglecting and neglectful parents, although most parents of this type fall within the normal range.

Because parenting style is a typology, rather than a linear combination of responsiveness and demandingness, each parenting style is more than and different from the sum of its parts (Baumrind, 1991). In addition to differing on responsiveness and demandingness, the parenting styles also differ in the extent to which they are characterized by a third dimension: psychological control. Psychological control "refers to control attempts that intrude into the psychological and emotional development of the child" (Barber, 1996, p. 3296) through use of parenting practices such as guilt induction, withdrawal of love, or shaming.

One key difference between authoritarian and authoritative parenting is in the dimension of psychological control. Both authoritarian and authoritative parents place high demands on their children and expect their children to behave appropriately and obey parental rules. Authoritarian parents, however, also expect their children to accept their judgments, values, and goals without questioning. In contrast, authoritative parents are more open to give and take with their children and make greater use of explanations. Thus, although authoritative and authoritarian parents are equally high in behavioral control, authoritative parents tend to be low in psychological control, while authoritarian parents tend to be high.

Consequences for Children

Parenting style has been found to predict child well-being in the domains of social competence, academic performance, psychosocial development, and problem behavior. Research based on parent interviews, child reports, and parent observations consistently finds:

• Children and adolescents whose parents are authoritative rate themselves and are rated by objective measures as more socially and instrumentally competent than those whose parents are nonauthoritative (Baumrind, 1991; Weiss & Schwarz, 1996; Miller et al., 1993).
• Children and adolescents whose parents are uninvolved perform most poorly in all domains.

In general, parental responsiveness predicts social competence and psychosocial functioning, while parental demandingness is associated with instrumental competence and behavioral control (i.e., academic performance and deviance). These findings indicate:

• Children and adolescents from authoritarian families (high in demandingness, but low in responsiveness) tend to perform moderately well in school and be uninvolved in problem behavior, but they have poorer social skills, lower self-esteem, and higher levels of depression.
• Children and adolescents from indulgent homes (high in responsiveness, low in demandingness) are more likely to be involved in problem behavior and perform less well in school, but they have higher self-esteem, better social skills, and lower levels of depression.

In reviewing the literature on parenting style, one is struck by the consistency with which authoritative upbringing is associated with both instrumental and social competence and lower levels of problem behavior in both boys and girls at all developmental stages. The benefits of authoritative parenting and the detrimental effects of uninvolved parenting are evident as early as the preschool years and continue throughout adolescence and into early adulthood.

Although specific differences can be found in the competence evidenced by each group, the largest differences are found between children whose parents are unengaged and their peers with more involved parents. Differences between children from authoritative homes and their peers are equally consistent, but somewhat smaller (Weiss & Schwarz, 1996). Just as authoritative parents appear to be able to balance their conformity demands with their respect for their children's individuality, so children from authoritative homes appear to be able to balance the claims of external conformity and achievement demands with their need for individuation and autonomy.

Sidebar:

Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Influence of Sex, Ethnicity, or Family Type

It is important to distinguish between differences in the distribution and the correlates of parenting style in different subpopulations. Although in the United States authoritative parenting is most common among intact, middle-class families of European descent, the relationship between authoritativeness and child outcomes is quite similar across groups. There are some exceptions to this general statement, however: (1) demandingness appears to be less critical to girls' than to boys' well-being (Weiss & Schwarz, 1996), and (2) authoritative parenting predicts good psychosocial outcomes and problem behaviors for adolescents in all ethnic groups studied (African-, Asian-, European-, and Hispanic Americans), but it is associated with academic performance only among European Americans and, to a lesser extent, Hispanic Americans (Steinberg, Dornbusch, & Brown, 1992; Steinberg, Darling, & Fletcher, 1995). Chao (1994) and others (Darling & Steinberg, 1993) have argued that observed ethnic differences in the association of parenting style with child outcomes may be due to differences in social context, parenting practices, or the cultural meaning of specific dimensions of parenting style.

Conclusion

Parenting style provides a robust indicator of parenting functioning that predicts child well-being across a wide spectrum of environments and across diverse communities of children. Both parental responsiveness and parental demandingness are important components of good parenting. Authoritative parenting, which balances clear, high parental demands with emotional responsiveness and recognition of child autonomy, is one of the most consistent family predictors of competence from early childhood through adolescence. However, despite the long and robust tradition of research into parenting style, a number of issues remain outstanding. Foremost among these are issues of definition, developmental change in the manifestation and correlates of parenting styles, and the processes underlying the benefits of authoritative parenting (see Schwarz et al., 1985; Darling & Steinberg, 1993; Baumrind, 1991; and Barber, 1996).

For More Information

1. Barber, B. K. (1996). Parental psychological control: Revisiting a neglected construct. Child Development, 67(6), 3296-3319.
2. Baumrind, D. (1989). Rearing competent children. In W. Damon (Ed.), Child development today and tomorrow (pp. 349-378). San Francisco: Jossey-Bass.
3. Baumrind, D. (1991). The influence of parenting style on adolescent competence and substance use. Journal of Early Adolescence, 11(1), 56-95.
4. Chao, R. K. (1994). Beyond parental control and authoritarian parenting style: Understanding Chinese parenting through the cultural notion of training. Child Development, 65(4), 1111-1119.
5. Darling, N., & Steinberg, L. (1993). Parenting style as context: An integrative model. Psychological Bulletin, 113(3), 487-496.
6. Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: Parent-child interaction. In P. H. Mussen (Ed.) & E. M. Hetherington (Vol. Ed.), Handbook of child psychology: Vol. 4. Socialization, personality, and social development (4th ed., pp. 1-101). New York: Wiley.
7. Miller, N. B., Cowan, P. A., Cowan, C. P., & Hetherington, E. M. (1993). Externalizing in preschoolers and early adolescents: A cross-study replication of a family model. Developmental Psychology, 29(1), 3-18.
8. Schwarz, J. C., Barton-Henry, M. L., & Pruzinsky, T. (1985). Assessing child-rearing behaviors: A comparison of ratings made by mother, father, child, and sibling on the CRPBI. Child Development, 56(2), 462-479.
9. Steinberg, L., Darling, N., & Fletcher, A. C. (1995). Authoritative parenting and adolescent adjustment: An ecological journey. In P. Moen, G. H. Elder, Jr., & K. Luscher (Eds.), Examining lives in context: Perspectives on the ecology of human development (pp. 423-466). Washington, DC: American Psychological Assn.
10. Steinberg, L., Dornbusch, S. M., & Brown, B. B. (1992). Ethnic differences in adolescent achievement: An ecological perspective. American Psychologist, 47(6), 723-729.
11. Weiss, L. H., & Schwarz, J. C. (1996). The relationship between parenting types and older adolescents' personality, academic achievement, adjustment, and substance use. Child Development, 67(5), 2101-2114.

Clearinghouse on Elementary and Early Childhood Education
Author: Nancy Darling, PhD, MS
EDO-PS-99-3

Reviewed by athealth on February 6, 2014.

Most parents worry about their child when he or she reaches adolescence. Will the child who was once easygoing and helpful become moody and disrespectful? Will the child who was fiercely independent when young become a teen who gives in to peer pressure? Will the child who has had a conventional style of dress suddenly color his or her hair purple?

When adopted children reach adolescence, their parents are likely to be anxious and have an additional set of questions. Will the child become confused about his or her identity? Will a sense of abandonment and rejection replace feelings of security and comfort? Is the child behaving in a way that reflects inner turmoil about the past? Each of these questions leads to a larger issue: Will being adopted make adolescence harder for the child?

These questions don't have simple answers. Only a few studies have compared the psychological well- being of adopted adolescents with that of nonadopted adolescents. Some of those studies conclude that having been adopted makes no difference in adolescent behavior. Others suggest that adopted teenagers are more likely than others to experience problems. Experts disagree about the relative importance of the role of parents, the "climate" of the family, and the natural temperament of the teenager as contributors to adolescent problems. There are two points on which they agree, however. (1) Being adopted is an undeniable part of a teen's history and should not be ignored. (2) Adopted adolescents can successfully confront and resolve their special developmental issues.

This factsheet is a guide to parents of adopted teenagers. It focuses on child development, typical adolescent behavior, the special issues of adopted teenagers, the times when parents should become concerned, and the steps parents can take to make these difficult years more manageable.

How Children Develop

From infancy on, children alternate between bonding with their caregivers and learning to become independent. Infants begin to gain independence by learning to crawl and then walk. As infants become toddlers, they start to give nonverbal and later verbal messages that express their wishes and opinions.

Up to about age 6, children absorb information rapidly, asking questions nonstop. They are able to think about being abandoned, getting lost, or no longer being loved by their parents. They often have trouble telling the difference between reality and fantasy. At the same time, they experience separation from loved ones as they attend preschool or daycare programs and broaden their interests and group of friends.

The inner lives of children take shape between the ages of 6 and 11. From the security of their families, children begin to expand their horizons and participate in more activities away from home. It can be a difficult time. Children must cement their sense of belonging to their family while mastering the knowledge and skills required for independence. It is no wonder that by the time they become teenagers their struggles to form an identity may feel overwhelming and may lead to perplexing, and sometimes troublesome, behavior.

Typical Adolescent Behavior

Adolescence is a trying time of life for both teenagers and their families. The physical aspects of adolescence - a growth spurt, breast development for girls, a deepening of the voice for boys - are obvious and happen quickly, whereas mental and emotional development may take years.

The main challenge for teenagers is to form their own identity - an achievement not nearly as simple as it sounds. It means, according to adoption experts Kenneth W. Watson and Miriam Reitz, that teenagers must define their values, beliefs, gender identification, career choice, and expectations of themselves.

In forming an identity, most adolescents try on a variety of personas. They look for, imitate, and then reject role models. They examine their families critically - idolizing some people, devaluing others. They shun or embrace family values, traditions, ideas, and religious beliefs. Sometimes they have enormous self-confidence; sometimes they feel at loose ends and think of themselves as utterly worthless. They may believe something one day, and then change their minds and think the opposite the next day. Ultimately, they must come to terms with the big questions: Who am I? Where do I belong?

Teenagers are acutely aware that they are growing away from their families. As they look for ways to demonstrate their individuality, they often take on the values, beliefs, and actions of others their age or of celebrities they admire. Even though they are trying to set themselves apart from their families, they often want to look, act, and dress just like their friends.

Teenagers are still dependent on their parents, however, and may veer back and forth between striking out and staying close. "Parents should realize," write Jerome Smith and Franklin Miroff in their book You're Our Child: The Adoption Experience, "that the adolescent is primarily a child and not an adult, except in the biological sense. Emotionally, he is still as dependent on his parents as always."

It is not surprising, therefore, that disagreements between parents and teenagers occur. Adolescents want independence, yet they are unsure how much freedom they can really handle. Parents want their teens to move toward self-sufficiency but often are reluctant to give up control. Teenagers are confused about their futures, and parents are anxious about who or what their sons and daughters will become.

Adolescents wrestle with issues of sexuality and spend time thinking about and wishing for romantic relationships. Parents worry about their teenagers' choices of partners and friends. Often, parents don't know what advice to give or how to give it.

Sidebar:

Children with ADHD and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. It is important that parents make themselves aware of their children's concerns and respond to them in positive, consistent, and supportive ways.

These kinds of tensions generally characterize the parent-teen relationship. There are additional issues for teens who came to their families through adoption.

Adoption and Adolescence

Adoption adds complexity to parenting adolescents. Adopted teenagers may need extra support in dealing with issues that take on special meaning for them - identity formation, fear of rejection and abandonment, issues of control and autonomy, the feeling of not belonging, and heightened curiosity about the past.

Identity Formation

Identity issues can be difficult for adopted teens because they have two sets of parents. Not knowing about their birthparents can make them question who they really are. It becomes more challenging for them to sort out how they are similar to and different from both sets of parents.

Adopted teenagers may wonder who gave them their particular characteristics. They may want answers to questions their adoptive parents may not be able to provide: Where do I get my artistic talent? Was everyone in my birth family short? What is my ethnic background? Do I have brothers and sisters?

Sixteen-year-old Jennifer explains, "I'm trying to figure out what I want to do in my life. But I'm so confused. I can't move ahead with my future when I don't know anything about my past. It's like starting to read a book in the middle. My big family with cousins and aunts and uncles only makes me aware that I'm alone in my situation. It never bothered me when I was younger. But now, for reasons I can't explain, I feel like a puppet without a string, and it's making me miserable."

Some teens may feel more angry at their adoptive parents than they have ever felt before. They may be critical of how their parents helped them adjust to their adoptive status. They may withdraw into themselves or feel they need to stray far from home to find their true identity.

Fear of Abandonment

Jayne Schooler, an adoption professional in Ohio and the author of Searching for a Past, writes that it is not unusual for adopted teenagers to fear leaving home. Leaving home is scary for most adolescents, but because adoptees have already suffered the loss of one set of parents, it is even more frightening.

Seventeen-year-old Caroline, for instance, who was adopted as an infant, seemed to have her future well in hand. She was offered a partial scholarship to play field hockey at an out-of-state university, and she planned to pursue a career in teaching. Her parents were eager to help their daughter move on to this next part of her life. However, perplexing changes occurred halfway through Caroline's final semester in high school. She began skipping classes. She was "forgetting" to do her homework. She spent more time than usual alone in her room. When her parents mentioned college, she ran into her bedroom and slammed the door.

At first her parents were puzzled. But they soon became alarmed when her grades dropped and her personality changed. They encouraged her to talk to a family friend who was a clinical psychologist. Several months of therapy helped Caroline and her parents understand that moving away from her family and familiar surroundings scared her. Perhaps if she were at school, her parents would forget about her. Maybe there would be no home to go back to. After all, it had happened before.

At her parents' suggestion, Caroline decided to put her college plans on hold for a year. She and her parents continued to participate in counseling to sort out the issues that were blocking her development.

The Badeaus of Philadelphia are the parents of 20 children, 18 of whom were adopted. They see a number of differences in the way their birth children and adopted children cope with separation. "Now that our birth children are adolescents - one's 12 and one's 14," says Sue Badeau, "we see that they are already talking about college...what they want to do when they grow up and how they can't wait to get out of the house! It's the complete opposite for our adopted kids. It seems really difficult for them to imagine themselves as independent people. They seem almost afraid to leave the security of the family."

Issues of Control

The tension between parents who don't want to give up control and the teenager who wants independence is the hallmark of adolescence. This tension may be especially intense for adopted teens who feel that someone else has always made decisions for them: the birthmother made the decision to place them for adoption; the adoptive parents decided whether to accept them. Parents may feel pressure to control their teens, sometimes motivated by concerns that their teens have a predisposition toward antisocial behavior - especially when their teens' birthparents have a history of alcoholism or drug abuse.

Parents worry, too, about their teens' sexual behavior. What if their son or daughter becomes sexually active, becomes or gets a partner pregnant, or gets AIDS? Adopted girls may have particular concerns about sexuality and motherhood. On the one hand, they have the adoptive mother, frequently infertile, and on the other, the birthmother, who had a baby but chose not to raise the child. How do adoptive parents help their daughters come to terms with these different role models?

Because of their fears, many adoptive parents tighten the reins precisely when their teenagers want more freedom. "Kids see it as - You don't trust me,'" says Anne McCabe, postadoption specialist at Tabor Children's Services in Philadelphia and a family therapist in private practice specializing in working with adoptive families. "It can strongly affect the trust level between parents and their teens." McCabe advises that parents and teens work together to identify options for building trust in important areas such as schoolwork, chores, choice of friends, choice of leisure time activities, and curfew. Parents and their teen can come to an agreement on what constitutes trustworthy behavior in each area. They can determine what privileges or consequences will be earned if the teen either demonstrates or doesn't demonstrate the behavior in an identified time frame. Both parties have input, and there are fewer power struggles.

The Feeling of Not Belonging

Teens raised in their birth families can easily see ways in which they are like their family members. Their musical talent comes from their grandmother...Their father also has red hair...Everyone in the family wears glasses. Sometimes adopted teens have no such markers, and, in fact, are reminded frequently that they are different from their nonadopted friends.

This feeling of being different often begins with their physical appearance. Friends frequently look like one of their parents or another relative. Teens who were adopted may not have a relative they resemble. Friends who comment, "You look like your sister," often make an adopted teen even more aware of his or her "outsider" status, even if he or she happens to look like the sister. Sometimes, adopted teenagers won't even correct friends who comment on a family resemblance. It is easier than having to answer the questions that are sure to follow: Who are your real parents? What do they look like? Why didn't they keep you?

"People who note a family resemblance are really trying to say that the child has taken on some of their parents' mannerisms," says McCabe. "In some families, it can become an inside joke. For other children, it can expose a raw nerve."

Teens who have been adopted into a family of a different race (transracial adoption) often feel more alienated from their families than they did when they were younger. They become highly conscious of the obvious physical differences between themselves and their families, and they struggle to integrate their cultural backgrounds into their perceptions of who they are. Some adopted teens may doubt their authenticity as "real" family members and, therefore, feel uncertain about their futures.

Adoptive parents can help transracially adopted teens to feel they belong by making sure that the family frequently associates with other adults and children of the same ethnic background as their teen. They should celebrate their own and their teen's culture as a part of daily life. They should talk about race and culture often, yet tolerate no ethnically or racially biased remarks from others. For further discussion of these and other suggestions for transracial families, see the National Adoption Information Clearinghouse factsheet, "Transracial and Transcultural Adoption." To increase the feeling of belonging for an adopted teen of the same race as his or her parents but who may look very different, parents should point out any similarities that exist between family members. Statements such as "Everyone in our family loves to sleep late on weekends" or "Dad and you are both such Rolling Stones fans, you're driving me crazy!" should be made whenever appropriate.

The Need to Connect With The Past

As adopted teens mature, they think more about how their lives would have been different if they had not been adopted or if they had been adopted by another family. They frequently wonder who they would have become under other circumstances. For them, the need to try on different personalities is particularly meaningful. In addition to all of the possibilities life holds, adoptees realize the possibilities that were lost.

For some adopted teenagers, the feelings of loss and abandonment cause them to think and want more information about their original families. Sometimes they are looking for more information about their medical history. Has anyone in their family had allergies? Heart disease? Cancer? Seventeen-year-old Sheila, who developed unexplained skin rashes, always wondered if others in her birth family had the same condition. As 18-year-old Christopher kept reading more articles about the genetic nature of mental illness, he worried that his mood swings might be an indication of manic-depressive illness that could have been present in his birth family. Adopted as a baby, Sally, now 15, says, "It's impossible for someone who has not been adopted to understand the vacuum created by not knowing where you came from. No matter how much I read or talk to my parents about it I can't fully explain the emptiness I feel."

Some teenagers want to search for their birthparents. Others say they would appreciate having access to medical information, but that they have made peace with their adoptions.

When Teens Were Adopted at an Older Age

Issues for teens adopted at an older age are even more complex. Often they endured abuse or neglect, lived in several foster homes, or moved from relative to relative before finding a permanent family. Their sense of loss and rejection may be intense, and they may suffer from seriously low self-esteem. They also can have severe emotional and behavioral difficulties as a result of early interruptions in the attachment process with their caregivers. It is no wonder that it is hard for them to trust adults - the adults in their early years, for whatever reason, did not meet their emotional needs.

Teens adopted at an older age bring with them memories of times before joining the adoptive family. It is important for them to be allowed to acknowledge those memories and talk about them. Parents of teens adopted at an older age can expect that they and their teens will require professional guidance at some point, or at several points, to help create and maintain healthy family relationships.

When Parents Should Become Concerned...What They Can Do

Adopted teens may experience strong emotions, especially related to their adoption. It would be unusual for their adopted status not to affect them. A teen's sense of abandonment, quest for identity, and need for control probably do not have their origin in poor parenting by the adoptive parents.

If a teen decides to search for his or her birthparents, it is not necessarily an indication of a problem. Research indicates that some adoptees simply have a strong need to know about their biological roots. "One of the misconceptions [that adoptive parents have]," says Marshall Schechter, M.D., professor emeritus in child and adolescent psychiatry at the University of Pennsylvania School of Medicine, "is that they have done something to make their child want to search. They haven't. Everyone needs to know that they are part of a continuum of a family ... As more is learned about genetics, scientists are discovering that many talents or personality traits have a genetic basis. So it should not be surprising that teenagers who focus on developing an identity should begin thinking about their origin."

It is more likely that a teen will have problems in families "where the parents insist that adoption is no different from the biological parent-child relationship," says Kenneth Kirby, Ph.D., from the Department of Clinical Psychiatry at Northwestern University School of Medicine in Chicago. Teens know that it is different. Teens do better when their parents understand their curiosity about their genetic history and allow them to express their grief, anger, and fear.

The following behaviors may indicate a teen is struggling with adoption issues:

• comments about being treated unfairly compared to the family's birth children;
• a new problem in school, such as trouble paying attention;
• a sudden preoccupation with the unknown;
• problems with peers; or
• shutting down emotionally and refusing to share feelings.

If your family style is one of open communication, you may be able to deal with these issues without professional help. Educate yourself through books or workshops run by agencies that provide postadoption services. Join an adoptive parent support group, which can be a valuable resource for families. The Clearinghouse can refer you to adoptive parent support groups in your area. Support groups also exist for adopted teenagers.

Chances are that if you have not been comfortable discussing adoption issues with your child in the past, it will be difficult to begin now. "The time to start talking about these issues is when children are younger," says MaryLou Edgar, postadoption specialist with Tressler Lutheran Children's Services in Wilmington, Delaware. "Otherwise, your kids know you aren't comfortable with the subject. It's like sex. One talk when your child is 12 isn't enough." Nonetheless, even if these discussions have not taken place earlier, it is up to the parents to initiate them with their teenagers, Edgar advises.

Many families benefit from seeing a therapist who specializes in working with adoptive families. Adoptive family organizations, adoption agencies in your area, and the Clearinghouse may be helpful in suggesting knowledgeable therapists. (See the Clearinghouse factsheet, "After Adoption: The Need for Services," for a discussion of the types of therapists. See Addendum II at the end of this factsheet for other tips.)

As with all teens, you should seek professional help if you see any of the following behaviors:

• drug or alcohol abuse;
• a drastic drop in grades or a sharp increase in skipping school;
• withdrawal from family and friends;
• risk taking; or
• suicide threats or attempt.

If adoption is part of the problem, openly addressing adoption issues will improve the chances that the treatment will be effective. Parents who recognize that their teens have two sets of parents and who don't feel threatened by that fact are more likely to establish a more positive environment for their teens, one that will make them feel more comfortable to express their feelings. "Kids know early on what subjects their parents are uncomfortable discussing and will avoid them," says McCabe. "Secrets take a lot of energy. When there is freedom to discuss adoption issues, there is much less of a burden on the family."

"There is a significant difference in the way teenagers perceive themselves when they have information about their birth families - ethnic heritage, abilities, education, or just what they looked like," says Marcie Griffen, postadoption counselor at Hope Cottage Adoption Services in Dallas, Texas. "When they know why they were placed for adoption, it tends to help their self-esteem and give them a better sense of who they are."

Sue Badeau understands her children's need to connect with their biological parents. She and her husband Hector agree that openness is important to the well-being of everyone in the adoption triad (adoptive parents, birthparents, and the adopted person). The Badeaus are committed to helping their children discover their roots if and when they want to. Recently, the Badeaus located the birthmother of four of their children: Flora, Sue Ann, Abel, and George. Flora, 13, was having trouble giving up the fantasy that her birthmother was going to come back for them so "they could live happily ever after." Sue and Hector persuaded their children's birthmother to assist them in helping Flora put her fantasies to rest. The birthmother helped Flora understand why she and her siblings were placed for adoption. Sue Ann was grateful for the chance to have some of her questions answered, but the boys wanted nothing to do with their birthmother at that time. "I keep telling all of my kids that their families did the best that they could," says Sue. "Birthmothers aren't the horrible monsters people make them out to be, but real people who make mistakes."

Conclusion

Adolescence can be a confusing time for teens. Adopted teens may have special issues connected to identity formation, rejection, control, and the need to connect with one's roots. It helps when parents are understanding and supportive. Questions surrounding these issues are not a reflection of adoptive parents' parenting style. Wanting to know about their birth family does not mean that adopted teens are rejecting their adoptive family.

If your family has a long-standing history of openness, honesty, and comfort with adoption, chances are that you will be able to help your teen work through adolescence. When openness has not been your family style, or if you see alarming behaviors such as drug use or withdrawal from enjoyable activities, you should seek professional help.

Mental health experts are confident that adopted teens can confront and resolve their developmental issues just as their nonadopted peers do. With the support and understanding of their parents, adopted teens can forge even stronger family bonds that will continue to nurture their future relationships.

Source:

National Adoption Information Clearinghouse

Author: Written by Gloria Hochman and Anna Huston of the National Adoption Center in Philadelphia, Pennsylvania, for the National Adoption Information Clearinghouse, 1995.

Reviewed by athealth on February 6, 2014.