When you take care of your body, you likely strive to eat right, stay active, and take care to look your best. Your mental health needs similar care. In fact, to be healthy overall, you need to take care of both your body and mind - the two are closely connected. If you neglect caring for one, the other will suffer. These ideas will help you to care for both mind and body:

• Build self-esteem. Good self-esteem is linked to mental well-being, happiness, and success in many areas of life.It protects mental health during tough times. One way to build self- esteem is to value who you are and what you do. This is hard to do if you judge yourself by other people's standards or rely on others to make you feel good about yourself. Instead, accept the qualities - both strengths and weaknesses - that make you unique.
• Set realistic standards and goals. Take pride in your achievements, both small and big. Positive thinking also boosts self-esteem. This comes naturally to some people. But it's a skill you can learn, too. Many people are lifted up by their spirituality. It can shape beliefs and values and be a source of comfort in hard times. It can be good to tune out the outside world and connect with the spirit within you.
• Find value and purpose in life. People who pursue goals based on their own values and dreams enjoy stronger mental well-being. Think about your values and dreams. What makes you happy? What do you care deeply about? What are you good at? If you could change one thing in the world,what would it be? What do you dream about? How do you want your friends and family to remember you? Use your answers to set short-term and long-terms goals for yourself. Keep your goals realistic. Review them every once in a while, and make changes as your values and priorities change.

• Learn healthy ways to cope with hard times. How do you react to stress,change, or hardship? Do you see setbacks as failures or merely bumps in the road? Do you avoid problems or look for solutions? Do you obsess about issues without taking action to resolve them? If your style needs improving, take heart: Positive coping styles and traits can be learned with some effort. If you have trouble improving thinking patterns on your own, a mental health professional can help. You might also benefit from life-skills classes. For example, parenting classes can prepare new mothers for what to expect. Being informed helps people to understand, control, and deal with situations that are new and stressful.
• Build healthy relationships. We need healthy relationships to grow, thrive,and sustain us in hard times. They also protect from loneliness and isolation, which can lead to depression.Surround yourself with people who encourage and support you. You might draw strength from your ethnic or cultural community. Relationships thatcause you to feel neglected, shameful, disrespected, or afraid are not healthy. Keep in mind that just as you need people, you are needed by others.Reach out and connect.

Source: Adapted from The Healthy Woman: A Complete Guide for All Ages
U.S. Department of Health and Human Services, Office on Women's Health
2008

Reviewed by athealth on February 8, 2014.

The Grief Of The Parents: A Lifetime Journey

Children are not supposed to die...Parents expect to see their children grow and mature. Ultimately, parents expect to die and leave their children behind...This is the natural course of life events, the life cycle continuing as it should. The loss of a child is the loss of innocence, the death of the most vulnerable and dependent. The death of a child signifies the loss of the future, of hopes and dreams, of new strength, and of perfection. - Arnold and Gemma 1994, iv, 9, 39

When a parent dies, you lose your past; when a child dies, you lose your future. - Anonymous

This space is with me all the time it seems. Sometimes the empty space is so real I can almost touch it. I can almost see it. It gets so big sometimes that I can't see anything else. - Arnold and Gemma 1983, 56

A wife who loses a husband is called a widow. A husband who loses a wife is called a widower. A child who loses his parents is called an orphan. But...there is no word for a parent who loses a child, that's how awful the loss is! - Neugeboren 1976, 154

Parental Grief

The theme of parental mourning has been a universal one throughout the centuries. In the literature on bereavement, writers repeat certain themes, thoughts, and reflections; they talk of the powerful and often conflicting emotions involved in "the pain of grief and the spiral of mourning; [they refer to] the heartbreak at the heart of things...grief's contradictions"; they speak of parents devastated by grief (Moffat 1992, xxiii).

It is frequently said that the grief of bereaved parents is the most intense grief known. When a child dies, parents feel that a part of them has died, that a vital and core part of them has been ripped away. Bereaved parents indeed do feel that the death of their child is "the ultimate deprivation" (Arnold and Gemma 1994, 40). The grief caused by their child's death is not only painful but profoundly disorienting-children are not supposed to die. These parents are forced to confront an extremely painful and stressful paradox; they are faced with a situation in which they must deal both with the grief caused by their child's death and with their inherent need to continue to live their own lives as fully as possible. Thus, bereaved parents must deal with the contradictory burden of wanting to be free of this overwhelming pain and yet needing it as a reminder of the child who died.

Bereaved parents continue to be parents of the child who died. They will always feel the empty place in their hearts caused by the child's death; they were, and always will be, the loving father and mother of that child. Yet, these parents have to accept that they will never be able to live their lives with or share their love openly with the child. So they must find ways to hold on to the memories. Many bereaved parents come to learn that "memories are the precious gifts of the heart...[that they need] these memories and whispers, to help create a sense of inner peace, a closeness" (Wisconsin Perspectives Newsletter, Spring 1989, 1).

Parental grief is boundless. It touches every aspect of [a] parent's being...When a baby dies, parents grieve for the rest of their lives. Their grief becomes part of them...As time passes, parents come to appreciate that grief is [their] link to the child, [their] grief keeps [them] connected to the child. - ARNOLD AND GEMMA, IN CORR ET AL. 1996, 50-51

Sociologists and psychologists describe parental grief as complex and multilayered and agree that the death of a child is an incredibly traumatic event leaving parents with overwhelming emotional needs. They also agree that this grief must be acknowledged and felt in its intensity. These experts repeatedly state that dealing with parental grief involves deep pain and ongoing work as the parents attempt to continue their "journey down the lonely road of grief" (Wisconsin Perspectives Newsletter, February 1997, 1).

Grieving parents say that their grief is a lifelong process, a long and painful process..."a process in which [they] try to take and keep some meaning from the loss and life without the [child]" (Arnold and Gemma 1983, 57). After a child's death, parents embark on a long, sad journey that can be very frightening and extremely lonely- a journey that never really ends. The hope and desire that healing will come eventually is an intense and persistent one for grieving parents.

The child who died is considered a gift to the parents and family, and they are forced to give up that gift. Yet, as parents, they also strive to let their child's life, no matter how short, be seen as a gift to others. These parents seek to find ways to continue to love, honor, and value the lives of their children and continue to make the child's presence known and felt in the lives of family and friends. Bereaved parents often try to live their lives more fully and generously because of this painful experience.

To those outside the family, the composition of the family may seem to change when a child dies. A sibling may become an only child; a younger child may become the oldest or the only child; the middle child may no longer have that title; or the parents may never be able to, or perhaps may choose not to, have another child. Nonetheless, the birth order of the child who died is fixed permanently in the minds and hearts of the parents. Nothing can change the fact that this child is considered a part of the family forever, and the void in the family constellation created by the child's death also remains forever.

In a newsletter for bereaved parents, one mother wrote, "It feels like a branch from our family tree has been torn off." Another grieving mother continues, "I felt that way too. A small branch, one whose presence completed us, had been ripped from our family and left a large wound. Without it, we were lopsided and off balance. When subsequent children are born, [they] do not replace the fallen branch, but create a new limb all their own" (Wisconsin Perspectives Newsletter, December 1996, 1).

Common And Individual Characteristics Of Parental Grief

Death is an experience that is common to all mankind, an experience that touches all members of the human family. Death transcends all cultures and beliefs; there is both commonality and individuality in the grief experience. When a loved one dies, each person reacts differently. A child's death, however, is such a wrenching event that all affected by it express sadness and dismay and are painfully shaken. Such a devastating loss exacts an emotional as well as a physical toll on the parents and family.

Bereavement specialists point to the commonalities of parental grief that may include an overwhelming sense of its magnitude, a sense that the pain will last forever, a sense that the grief is etched into one's very being. They explain that it is also important for these parents to express their anger outwardly so that it will not turn inward and possibly become a destructive force in the future. These specialists say that although there are many commonalities in parental grief, individual reactions often vary and that the same person may even experience contradictory reactions. They also say that the two responses experienced most commonly by bereaved parents are a baffling sense of disorientation and a deep conviction that they must never let go of the grief.

But there are also many unique ways that bereaved parents express their grief. These individual parental responses are influenced by many factors including the person's life experiences, coping skills, personality, age, gender, family and cultural background, support and/or belief systems, and even the death or the type of death that occurred.

Parental grief is boundless. It touches every aspect of the parent's being...The range of expression of parental grief is wide...Some parents will express tears and hysteria openly. Others will silence these expressions and grieve inwardly...Despite the volumes of work on grief, the experience of grief seems to defy description... Definitions touch the fringes of grief but do not embrace its totality or reach its core...Grief is a complicated, evolving human process. Grief is a binding experience; its universality binds sufferers together. More is shared than is different. - ARNOLD AND GEMMA, IN CORR ET AL. 1991, 50-52, 55

As part of the grieving process, bereaved parents experience ups and downs and a literal roller coaster of emotions. For these parents, a personal history includes a past with the child and a present and future without the child. For most grieving parents, it is vitally important to verbalize the pain, to talk about what happened, to ask questions, and puzzle aloud, sometimes over and over.

It is the nature of grief that feelings, thoughts, and emotions need to be processed and that those in grief must look into their hearts and souls and try to heal from within. Each does this in his/her own way. "Grieving parents are survivors" (Rando 1986, 176), and each survivor travels this lonely and painful road in a way each maps out. In traveling this road, parents often respond differently, learn to live with their grief separately, and express their sadness uniquely. Grieving parents can and often do feel alone, disconnected, and alienated. They need to know that there are many ways to grieve; there is no timetable for grief's duration; there are no rules, boundaries, or protocols for grieving.

Moreover, those who seek to comfort grieving parents need to recognize and understand the complexities of the parents' emotions and should avoid relying on preconceived ideas about the way a couple is supposed to grieve if their child dies. Reactions of grieving parents may seem overly intense, self-absorbing, contradictory, or even puzzling. For bereaved parents, the death of a child is such an overwhelming event that their responses may often be baffling not only to others but to themselves as well.

The sorrow for the dead is the only sorrow from which we refuse to be divorced. Every other wound we seek to heal, every other affliction to forget; but this wound we consider it a duty to keep open; this affliction we cherish and brood over in solitude. - WASHINGTON IRVING, THE SKETCH BOOK , IN MOFFAT 1992, 270

Parental Grief And A SIDS Death

The impact of a Sudden Infant Death Syndrome (SIDS) death presents unique grieving factors and raises painful psychological issues for the parents and family as well as those who love, care for, and counsel them. SIDS parents must deal with a baby's death that is unexpected and unexplained, a death that cannot be predicted or prevented, an infant death so sudden that it leaves no time for preparation or goodbyes, and no period of anticipatory grief. In many cases, parents of SIDS babies are very young and are confronted with grief for the first time.

SIDS often occurs at home, forcing parents and siblings or other children to witness a terrible tragedy and possibly scenes of intense confusion. In some cases, the parents themselves are the ones who find the child dead and they must always live with that memory. In other cases, the parents may feel overwhelming guilt or anger if the death occurred while the child was in daycare. They may feel that the baby might not have died if they had been caring for it. "All too frequently, a SIDS loss is not socially validated in the same way other deaths are. Others often fail to recognize that, despite the brevity of the child's life, the family's attachment to that child is strong and deep and has been present in various ways since the knowledge of conception" (Rando 1986,167).

SIDS parents must take a journey that "involves a trek through grief-a strange and hostile territory that no one would ever pass through if given the choice" (Horchler and Morris 1994, 17). SIDS parents often retain strong feelings of guilt and sometimes a sense of responsibility for what happened even though they've been told there was nothing they could have done to prevent the death. Sometimes, parents are the victims of undeserved suspicion from law enforcement personnel, even family members, neighbors, or friends. In the most difficult situations, the baby's death may cause parents to be subjected to grueling investigations and hostile questions; they may even face accusations of child abuse.

Probably the most stressful and anxiety-provoking act in human existence is the separation of a woman from her newborn infant. The response to this, which humans share with most of the animal kingdom, is an overwhelming combination of panic, rage, and distress. - RUSKIN, IN HORCHLER AND MORRIS 1994,16

SIDS parents, relatives, daycare providers, health care professionals, and other adults feel helpless in trying to explain the unexplainable to other young children who may have been present at the time of the baby's death. It is especially difficult for children to understand why a baby died when it didn't appear to be sick. Also, in some cases parents are required to explain SIDS to adults who are misinformed or know nothing about the syndrome.

Any infant or early childhood death forces adults to think about their own vulnerability, but a SIDS death also brings with it total mystery, an absence of answers, and a frightening loss of control. The chaos surrounding a SIDS death leaves most parents feeling that nothing in life is predictable; a SIDS death throws everything off balance.

As is the case in most traumatic experiences, SIDS parents are likely to continually replay the events surrounding the death over and over in their minds and in their conversations. Whether the parents put a seemingly healthy baby down for a nap or for the night or took the child to the daycare provider, they assumed their child was well and in a protected environment. They felt secure; their family and their world were in order. Then suddenly, everything has been turned upside down. Even though there may be attempts to reassure the parents that the baby didn't appear to suffer, frequently they are not convinced. They repeatedly ask, "How can a perfectly healthy baby die?" Often these parents are told that SIDS doesn't carry a high hereditary risk; yet fears about having subsequent children haunt them.

[The grief SIDS parents feel is like a]...continuous, crashing waterfall of pain...SIDS is a forced separation that will last forever. In the beginning, survivors are so shocked that their bodies and minds cannot even begin to comprehend all that has been lost...Shock and disbelief overtake most survivors so they can only vaguely feel their own empty arms and the rage that will eventually come full force. ...SIDS parents attempt to transcend the awfulness of [the baby's] death by choosing to celebrate the dead infant's life while not denying the physical finality of the death...[After a SIDS death, parents attempt] to travel the long road of grief to a place of rest and hope...SIDS parents must [try to] actively seek peace and joy in life-even in the face of a grief that will never end... - HORCHLER AND MORRIS 1994, 2, 16, 17, 248

SIDS parents also are very often plagued by "if only's" that they are never able to resolve. They mentally replay such thoughts as: "If only I hadn't put the child down for a nap when I did." "If only I had checked on the baby sooner." "If only I had not returned to work so soon." "If only I had taken the baby to the doctor with that slight cold."

SIDS parents also need to know the value and importance of obtaining reliable information. They need to have access to professional support; and they need to be aware of the great benefits other parents have gained from attending support groups and sharing their experience or by expressing their thoughts and feelings in writing.

Moreover, bereaved SIDS parents often find that health care professionals are as perplexed as they are and cannot provide them with any explanation for the death. Although most health professionals know about SIDS, not all can provide parents with the information they so anxiously seek. They are unable to provide answers to questions such as: "Did my baby suffer?" "What are the possible causes of SIDS?" "What can I do to prevent another child from dying of SIDS?" "Are there symptoms I should have known about that could have prevented the death?"

In the case of some SIDS deaths, the autopsy findings may still leave unanswered questions, or the child's death may be attributed to causes that are problematic for the parents. Some families are subjected to agonizing doubts and delays from the legal system about the exact cause of death. The absence of standardized procedures for determining the cause of unexpected infant deaths brings added pain and frustration to parents already in the midst of a harrowing nightmare. Thus, SIDS parents are often denied the sense of closure that comes from knowing the exact cause of their baby's death.

A single SIDS death can have a ripple effect on as many as 100 people who came in contact with the baby or the family. "The expanded circle of concern" (Corr et al. 1991, 43) can include parents, extended family, neighbors, coworkers, child care providers, health care and emergency personnel, clergy, funeral directors, and other care providers.

SIDS parents and family members need to be around people who will offer them support in a nonjudgmental way; they need to know that some things in their lives are permanent and there are certain people on whom they can truly depend. Other family members, friends, or professionals can provide this sense of dependability and assurance by allowing parents both permission and ways to express their grief and talk about their confusion. SIDS parents need to talk and they need someone to listen-really listen-even if they tell their story, express their doubts and fears, and ask the same questions repeatedly. What SIDS and other bereaved parents are really saying is, "Let me tell you about my pain; let me talk about my child with you; please do call my child by name; please do not let my child be forgotten."

Friends and family members should try to do all they can to show their concern and help the parents in keeping alive memories of their baby. For most SIDS parents, it is also reassuring for others to try to mention special things they noticed about the baby and to remember the child's birthday or the anniversary of the death. By extending these personal and sensitive gestures, loving and concerned relatives, friends, and caregivers can become a source of reassurance and comfort for the grieving parents.

Some SIDS babies are so young when they die that family members and friends never had a chance to welcome them. They may have missed sharing the parents' excitement over the birth and affirming the child's existence. Many individuals do not understand the depth of parental attachment to a very young child. Bereaved SIDS parents should not be made to feel that others don't want to hear them, that others won't permit them to openly grieve. The parents of SIDS babies want their child's short life to matter not only to them, but to their families and friends, to the others in their "circle of concern," to the world.

The dynamics of a SIDS loss [mean]...there is no chance to say goodbye to the infant or to absorb the reality of the loss gradually over time; the unexpected loss so overwhelms people that it reduces their functioning and compromises their recovery...The physical and emotional shock of the infant's death undermines the [parents'] capacity for regaining a feeling of security; the SIDS loss evokes particularly problematic grief reactions, such as the abrupt severing of the mother and father infant bond. - RANDO 1986, 166

Fathers - The Forgotten Grievers

The death of a child is probably the most traumatic and devastating experience a couple can face. Although both mothers and fathers grieve deeply when such a tragedy occurs, they grieve differently, and it is most important that each partner give the other permission to grieve as he/she needs. This may be the greatest gift each can give the other.

Parental grief is strongly influenced by the nature of the bond between child and parent. Bereavement specialists actually speak of "incongruent grieving" patterns in mothers and fathers and of differences in the timing and intensity of the parental bond for mothers and fathers.

For the mother, the bond is usually more immediate and demonstrable, more intense at the beginning of life, more emotionally and physically intimate. The mother's bond with the baby is usually tightly forged from the moment of conception and continues through the pregnancy, the birth, and the nursing process. The maternal bond involves the present and the baby's immediate needs, while the father's bond with the baby more often concerns the future and dreams and expectations for the child. Today, however, many fathers are forging earlier and more intense prenatal bonds with their babies. Fathers also are often present in the delivery room for the birth. Some fathers become direct caregivers of the newborn, developing early and close bonds with their infants. Yet, still in many cases, "the father's emotional investment in parenting tends to occur later and less intensely than the mother's. This has implications for the way parents grieve" (Cordell and Thomas 1990, 75).

When is it my turn to cry? I'm not sure society or my upbringing will allow me a time to really cry, unafraid of the reaction and repercussion that might follow. I must be strong, I must support my wife because I am a man. I must be the cornerstone of our family because society says so, my family says so, and, until I can reverse my learned nature, I say so. - A FATHER, IN DEFRAIN ET AL. 1991, 112

In spite of the trend towards earlier bonding between fathers and babies, the influence of cultural expectations about men and grief persists and is powerful. Typically, the societal view of parental loss is not the same for the father as the mother. Most of the literature on parental bereavement still tends to focus on the mother's grief. Often, men are not acknowledged as experiencing grief; or more importantly, men are not taught that it's necessary to grieve and are discouraged from demonstrating signs of grief openly. Bereaved fathers frequently feel that they are the forgotten mourners and are often referred to as "second class grievers" (Horchler and Morris 1994, 72).

Fathers are expected to be strong for their partners, to be the "rock" in the family. All too often fathers are considered to be the ones who should attend to the practical but not the emotional aspects surrounding the death; they are expected to be the ones who should not let emotions show or tears fall outwardly, the ones who will not and should not fall apart. Men are often asked how their wives are doing, but not asked how they are doing.

Such expectations place an unmanageable burden on men and deprive them of their rightful and urgent need to grieve. This need will surface eventually if it is not expressed. It is not unusual for grieving fathers to feel overwhelmed, ignored, isolated, and abandoned as they try to continue to be caregivers and breadwinners for their families while their hearts are breaking. "Fathers' feelings [often] stay hidden under layers of responsibility and grim determination" (Staudacher 1991, 124).

Bereaved fathers often say that such strong emotions are very difficult to contain after their child's death. Fathers often fear that they will erupt like volcanoes if they allow themselves to release these feelings and so, too often, fathers try to bury their pain with the child who died.

It is most important that a father's grief be verbalized and understood by his partner, other family members, professionals, coworkers, friends, and by anyone who will listen. Fathers need to try to free themselves of stereotypes and societal expectations about men and grief; they must be able to tell others that their grief is all they have from their child's brief life. Fathers repeatedly say that for their own peace of mind, they (and those who care about them) need to move away from this mind set and allow them to grieve as they are entitled.

In too many instances, fathers' responses to infant loss tend to coincide with how they believe they should act as men, rather than how they need to act to confront and resolve [their own] grief. - CORDELL AND THOMAS 1990, 75

The Impact Of Grief In Special Parenting Situations

The tragedy of a child's death brings profound pain to all affected, and it presents incredibly difficult and unusual problems for grieving parents. For some parents, the effects of such a complicated and devastating tragedy can be further compounded when the death occurs in what are already trying family situations. There are some parents for whom there is no established "circle of concern"; there are some parents for whom there is no safety net; there are some parenting situations that are outside the domain of the typical support network; and there are some parents who choose to reject this network for their own reasons.

A child's death may present unique dilemmas for:

• Single parents who are often self-supporting and may be more isolated and ignored
• Unmarried parents who may already have experienced the disfavor of family and others
• Teenage parents whose grief is often not validated because of their situation or their youth
• Parents in stressful financial situations whose struggle to satisfy their most basic needs may cause them to stifle or ignore their need to grieve and for whom loss is a constantly repeated theme
• Divorced parents and parents in blended or nontraditional families who may require unique responses or resources
• Step-parents whose grief may not be understood or appreciated
• Adoptive parents who may be expected to grieve less than birth parents because their "bond" with the child is perceived to be less intense n Foster parents who are not thought to have the same "right" to grieve as birth parents
• Parents who experience the death of the only child they may ever have and who also grieve for the loss of their parenting role
• Parents losing a child who is one in a multiple birth and who are faced with the double task of saying "goodbye to the baby who has died and yet...still loving and caring for the baby who is living" (Hosford 1994, 1)
• Parents who are removed or estranged from typical and traditional support systems
• Parents whose language, cultural traditions, and/or beliefs are largely unrecognized or misunderstood by the society
• Parents in homeless shelters, prisons, jails, or other institutions whose needs require unique consideration and creative responses
• Parents with substance abuse problems whose child may have faced medical and/or developmental problems and who often must deal with guilt and other complex and overwhelming problems when a child dies.

When a child dies, inevitably there will be additional factors that will impinge on the parent's grief experience. Some of these will be negative... [and] sometimes, these factors will be positive. - RANDO 1986, 31

All of the grieving parents identified above as well as parents in many other situations may find their grief unusually complicated. They may discover the responses of others to be less concerned and may find support networks less readily available. These parents may not receive the same validation as parents in traditional nuclear families, and the needs and wishes of parents in these unique and complex situations may sometimes be ignored or misunderstood. Parental experiences, coping strategies, and cultural differences vary widely. At the same time, these parents may not have the same access to, need for, or reliance on peer or other support groups. Obtaining transportation or babysitters so they can attend meetings may be an impossibility for some parents. Still others may reject such support networks and depend solely on family, neighborhood, or church networks as the best support system for them. Parental bereavement support groups are not for everyone.

All of the parents exemplified here find themselves in special situations affecting their personal grief experience, how others react to their grief, and the type of support and/or intervention needed to help them resolve their grief. However, these parents are the fathers and mothers of the child who died; they are the ones who have nurtured, cared for, and loved that child. The sense of absolute emptiness, the lack of wholeness, and the feeling of diminishment after the death of a child are felt by all parents, regardless of marital status; age; language; financial or social circumstances; biological relation to the child; or cultural, racial, or religious background. Despite the differences among these groups in their responses and needs, all have one major need in common-their grief is intense and must be acknowledged.

There is no relationship like that of parent and child. It is unique and special...The bond between parent and child is so powerful that its strength endures time, distance, and strife. No loss is as significant as the loss of a child...On the death of a child, a parent feels less than whole. - ARNOLD AND GEMMA 1994, 25-27

From One Grieving Parent To Another

You will always grieve to some extent for your lost child. You will always remember your baby and wish beyond wishes that you could smell her smell or hold his weight in your arms. But as time goes on, this wishing will no longer deplete you of the will to live your own life. - HORCHLER AND MORRIS 1994, 158

• Parental grief is overwhelming; there is nothing that can prepare a parent for its enormity or devastation; parental grief never ends but only changes in intensity and manner of expression; parental grief affects the head, the heart, and the spirit.
• For parents, the death of a child means coming to terms with untold emptiness and deep emotional hurt. Immediately after the death, some parents may even find it impossible to express grief at all as many experience a period of shock and numbness.
• All newly bereaved parents must find ways to get through, not over, their grief-to go on with their lives. Each is forced to continue life's journey in an individual manner.
• Parental bereavement often brings with it a sense of despair, a sense that life is not worth living, a sense of disarray and of utter and complete confusion. At times, the parent's pain may seem so severe and his/her energy and desire to live so lacking that there is uncertainty about survival. Some bereaved parents feel that it is not right for them to live when their child has died. Others feel that they have failed at parenting and somehow they should have found a way to keep the child from dying.
• Grieving parents often have to adopt what one parent called a "new world view" (Wisconsin Perspectives Newsletter, December 1996, 7). Each parent must almost become a new and different person.
• Grieving parents should learn to be compassionate, gentle, and patient with themselves and each other. Grief is an emotionally devastating experience; grief is work and demands much patience, understanding, effort, and energy.
• Parental grief can and often does involve a vast array of conflicting emotions and responses including shock and numbness, intense sadness and pain, depression, and often feelings of total confusion and disorganization. Sometimes, parents may not even seem sure of who they are and may feel as if they have lost an integral part of their very being. At other times, parents may feel that what happened was a myth or an illusion or that they were having a nightmare.
• Typical parental reactions to a child's death often involve emotional and physical symptoms such as inability to sleep or a desire to sleep all the time, mood swings, exhaustion, extreme anxiety, headaches, or inability to concentrate. Grieving parents experience emotional and physical peaks and valleys. They may think life finally seems on an even keel and that they are learning to cope when periods of intense sadness overwhelm them, perhaps with even more force. (Experiencing any or all of these reactions does not mean permanent loss of control or inability to recover and are usually part of the grief process.)
• The death of a child can and often does affect not only personal health but sometimes the marriage, the entire family unit, other relationships, and even plans and goals for the future.
• Grieving parents need to know how important it is to express their pain to someone who will understand and acknowledge what they are feeling and saying. They should be honest with themselves and others about how they feel. These parents should allow themselves to cry, be angry, and complain. They need to admit they are overwhelmed, distracted, and unable to focus or concentrate. They may even need to admit to themselves and others that they might show physical and/or emotional symptoms that they don't want or can't even understand.

When are you ready to live again? There is no list of events or anniversaries to check off. In fact, you are likely to begin living again before you realize you are doing it. You may catch yourself laughing. You may pick up a book for recreational reading again. You may start playing lighter, happier music. When you do make these steps toward living again, you are likely to feel guilty at first. 'What right have I, you may ask yourself, to be happy when my child is dead?' And yet something inside feels as though you are being nudged in this positive direction. You may even have the sense that this nudge is from your child, or at least a feeling that your child approves of it. - HORCHLER AND MORRIS 1994, 158

• Each bereaved parent must be allowed to mourn in his/her own way and time frame. Each person's grief is unique, even that of family members facing the same loss. Bereaved parents shouldn't expect or try to follow a specific or prescribed pattern for grief or worry if they seem out of synchrony with their partner or other grieving parents.
• Bereaved parents need to know that others may minimize or misunderstand their grief. Many don't understand the power, depth, intensity, or duration of parental grief, especially after the death of a very young child. In some instances, bereaved parents are even ignored because some individuals are not able to deal with the tragedy. They find the thought of a child's death too hard, too Inexplicable, or too threatening. Many simply don't know what to say or do and so don't say or do anything.
• Most grieving parents experience great pain and distress deciding what to do with their child's belongings. Parents need to under-stand that this task will be most difficult and that different parents make different decisions. They should be encouraged to hold onto any experiences, memories, or mementoes they have of the child and find ways to keep and treasure them. These memories and mementoes-their legacy from the short time they shared with this very special person- will be affirming and restorative in the future.
• Most grieving parents also experience considerable pain on special occasions, such as birthdays, holidays, or the anniversary of the child's death. Parents will need to find ways to cope with these events and should do what feels right for them, not what others think they should do.
• Many bereaved parents find solace in their religion. Not only will these religious beliefs significantly alter the meaning that the parents give to life, death, and life after death, they will also affect their grief response. Grieving parents with a religious background should be encouraged to express these beliefs if this is helpful. Some grieving parents without a formal or organized religious background may maintain a spirituality or a personal faith that is also a part of their lives and that gives them comfort. They, too, should be encouraged to express these feelings. Seeking spiritual comfort in a time of grief does not mean repressing the grief. (It is important, however, that others offering support to grieving parents should not try to dismiss or diminish their grief by using religious or other platitudes or by forcing religion on parents who are uncomfortable with a particular belief system.)

Bereaved parents will recover and reach a place of rest and hope... [They] will never forget [their child], but rather will find ways to keep [the child] a cherished part of [their] inner selves forever. - HORCHLER AND MORRIS 1994, XIX

• Many grieving parents also find comfort in rituals. Funerals or memorial services have served many parents as beautiful and meaningful ways of saying goodbye, providing a sense of closure after the child's death. For others, sending announcement cards about the baby's death, writing poems, keeping journals or writing down personal reflections or prayers, or volunteering with a parental bereavement group become ways to remember and honor the child who died.
• Grief is the natural response to any loss. Parents need to be reminded how important it is to process all feelings, thoughts, and emotions in resolving grief. Bereaved parents must look within and be prepared to deal with the past and present. They need to talk about their loss, and the loss must be acknowledged by others. They need to tell others about what happened to their child; they need to talk out and through their thoughts and feelings from the heart, not just from the head. Healing for bereaved parents can begin to occur by acknowledging and sharing their grief.
• Probably the most important step for parents in their grief journey is to allow themselves to heal. Parents need to come to understand that healing doesn't mean forgetting. They need to be good to themselves and absolve themselves from guilt. They should not be afraid to let grief loosen its grip on them when the time comes. Easing away from intense grief may sometimes cause pain, fear, and guilt for a while, but eventually, it usually allows parents to come to a new and more peaceful place in their journey. Allowing grief's place to become a lesser one does not mean abandoning the child who died.

In the end parents must heal themselves. It was their baby; it is their loss; it is their grief. They need to gain closure, to experience release, to look to their new future. - NICHOLS, IN RANDO 1986, 156

Some Thoughts From Grieving Parents

• Bereaved parents face a devastating and difficult journey; expressing grief is the normal response to such a loss; unexpressed grief can be devastating and debilitating.
• An intense parental attachment has been formed between parent and child no matter how young the child is at the time of death. Others need to try and understand the intensity of this attachment, the depth of the parents' grief, and the magnitude of their sorrow.
• Grief is exhausting and demanding work. Grief is also a process, not a single timed event. Bereaved parents appear to exhibit different reactions at varying points in their grief and to grieve differently even when they belong to the same family.
• There are no easy ways to deal with grief, there is no one correct way to grieve, and no set time frame for grieving parents.
• Caregivers need to know there are no exact or right words or expressions when comforting grieving parents. Neither should caregivers try to take away the parents' grief. Most of all, they should try to speak from the heart and show their care and concern. Sometimes it may seem that they say the wrong thing.
• The caregiver should try again, using different words, or admit confusion about what to say. The pain must be walked through by the bereaved parent and also by those who seek to help them.

There is a need to talk, without trying to give reasons. No reason is going to be acceptable when you hurt so much. A hug, the touch of a hand, expressions of concern, a willing listener were and still are the things that have helped the most...The people who [were] the greatest help... [were] not judgmental. It's most helpful when people understand that [what is needed] is to talk about it and that this is part of the grief process. - DEFRAIN ET AL. 1991, 158, 163

• Bereaved parents need to find ways to keep the memories alive and also find ways to create memories. Memories are all they have left from the child who died. Bereaved parents often need to establish unique rituals to memorialize the child and in some cases, others may find this process puzzling.Grieving parents need to be allowed to set the tone and direct others about how to help them in their grief. Parents need validation as they attempt the process of healing.
• Friends and caregivers should try to help grieving parents express their grief. They should try to be a safe place for them-a place where they can be themselves, where they can be confused, where they can express their pain, sadness, and even anger. Those who care should grieve and mourn with the parents; they must also be willing to listen.
• In most cases, bereaved parents don't want to be avoided, but they may be hesitant to let others know they are needed. Usually, they are most grateful for the kind expressions and gestures of love and support.
• Bereaved parents need to know that the support of family, friends, and others will continue after the commotion and busy days immediately following the death and funeral. Their grief continues forever. One bereaved father said, "the period following the funeral is perhaps the most difficult time for the bereaved...[This is the time that parents must] absorb the magnitude of their loss and begin to integrate it into the rest of their lives" (Bramblett 1991, 39). Bereaved parents need to have extended remembrances of their child for a long while after the event, especially on anniversaries, birthdays, holidays, or special events, such as Mother's Day or Father's Day.
• Bereaved parents need to know that their child will be remembered, not just by them but also by family and friends. They need to have the child acknowledged and referred to by name. They want that child's life to matter. They do not want to forget and they don't want others to forget. One bereaved parent said, "The mention of my child's name may bring tears to my eyes, but it also brings music to my ears" (Anonymous).

Grieving keeps memories alive for bereaved parents and retains a place in their families and in their hearts for the dead child...[it is] a continuous process with peaks, valleys, and plateaus; it is a complex process that varies with each individual. - Arnold and Gemma 1994, 1994, 28

When Trying To Comfort Grieving Parents

DO:

• Acknowledge the child's death by telling the parents of your sadness for them and by expressing love and support; try to provide comfort.
• Visit and talk with the family about the child who died; ask to see pictures or mementoes the family may have.
• Extend gestures of concern such as bringing flowers or writing a personal note expressing your feelings; let the parents know of your sadness for them.
• Attend the child's funeral or memorial service.
• Remember anniversaries and special days.
• Donate to some specific memorial in honor of the child. Offer to go with the parent(s) to the cemetery in the days and weeks after the funeral, or find other special ways to extend personal and sensitive gestures of concern.
• Make practical and specific suggestions, such as offering to stop by at a convenient time, bringing a meal, purchasing a comforting book, offering to take the other children for a special outing, or treating the mother or father to something special.
• Respect the dynamics of each person's grief. The often-visible expressions of pain and confusion shown by grieving parents are normal. Grief is an ongoing and demanding process.

DO NOT:

• Avoid the parents or the grief. Refrain from talking about the child who died or referring to the child by name.
• Impose your views or feelings on the parents or set limits for them about what is right or appropriate behavior.
• Wait for the parents to ask for help or tell you what they need.
• Tell them you know just how they feel.
• Be afraid to let the parents cry or to cry with them.

How Grieving Parents Attempt To Cope With The Loss And Move On

• Bereaved fathers and mothers try to cope with their grief by:
• Admitting to themselves and others that their grief is overwhelming, unpredictable, painful, draining, and exhausting-that their grief should not be diminished or ignored.
• Allowing themselves to be angry and acknowledging that they are vulnerable, helpless, and feeling disoriented.
• Trying to understand that to grieve is to heal and that integrating grief into their lives is a necessity.
• Acknowledging the need and desire to talk about the child who died as well as the moments and events that will be missed and never experienced with the child.
• Maintaining a belief in the significance of their child's life, no matter how short.
• Creating memorial services and other rituals as ways to commemorate the child's life.
• Deriving support from religious beliefs, a sense of spirituality, or a personal faith.
• Expressing feelings in journals, poetry, prayers, or other reflective writings or in art, music, or other creative activities.
• Trying to be patient and forgiving with themselves and others and refraining from making hasty decisions.

When you accept what has happened, you aren't acknowledging that it is okay but rather, that you know you must find a way to keep growing and living-even if you don't feel like it...[Don't let] grief be your constant companion...Realize that your grief is born out of unconditional love for your child and rejoice in that love which will never end... Embracing life again is not a sign that you have stopped missing your baby, but an example of a love that is eternal. - WISCONSIN PERSPECTIVES NEWSLETTER, SPRING 1989, 3

• Counting on, confiding in, and trusting those who care, listen, and hear, those who will walk with them, and not be critical of them, those who will try to understand their emotional and physical limitations.
• Increasing their physical activity and maintaining a healthful diet.
• Volunteering their services to organizations concerned with support for bereaved parents.
• Obtaining help from traditional support systems, such as family, friends, professionals or church groups, undergoing professional counseling, joining a parent support group, or acquiring information on the type of death that occurred as well as about their own grief.**
• Reassuring themselves and others that they were and still are loving parents.
• Letting go of fear and guilt when the time seems right and the grief seems less.
• Accepting that they are allowed to feel pleasure and continue their lives, knowing their love for their child transcends death.

** Grief support groups are often available through area hospitals, churches, or local chapters of national organizations, such as State SIDS or SIDS Alliance programs or through support organizations, such as SHARE, Resolve Thru Sharing, Compassionate Friends, and others.
When children die, the bond doesn't break... [But] the parents face two mutually exclusive facts. The child is gone and not coming back, and the bond is...as powerful a bonding as people have in their abilities... [Bereaved parents attempt] to let go, not of the child, but of the pain. - FINKBEINER 1996, 244, 249

Conclusion

Children are valuable and precious symbols of what lies ahead. Children are considered the hope of the future. When a child dies, that hope is lost.

Two universals stand out when reflecting on parental grief-a child's death is disorienting, and letting go of a child is impossible. Parents never forget a child who dies. The bond they formed with their child extends beyond death. As survivors, bereaved parents try to adapt to the new existence forced on them. They try to pass on to others the love and other special gifts they received from their child; they try to make the child who died a part of their lives forever; they constantly try to "honor the child who should have lived" (Finkbeiner 1996, xiv). Bereaved parents encourage others who care for and about them to do the same. They ask others to help them, to be for them "a lifeline of support, a lifeline to survival [and to understand]...the crying of their souls" (Donnelly 1982, ix).

Bereaved parents say, "Our children are in our blood; the bond with them doesn't seem to break [and they attempt to] find subtle and apparently unconscious ways of preserving that bond" (Finkbeiner 1996, xiii, xiv). Bereaved parents need to do this to deal with what seems like an endless roadblock of loss and sadness. One bereaved parent expressed it by saying that the wound heals, but the scar remains forever.

What has happened to these parents has changed their lives; they will never see life the same way; they will never be the same people. As they attempt to move forward, bereaved parents realize they are survivors and have been strong enough to endure what is probably life's harshest blow. By addressing their grief and coping with it, they struggle to continue this journey while making this devastating loss part of their own personal history, a part of their life's story, a part of their very being.

Bereaved parents learn to live with the memories, the lost hopes, the shattered dreams. [They] never 'get over' the death, but [they] do recover, adjust and learn to live with [the] pain. - DONNELLY 1982, X

In writing about bereavement, Rollo May, the religious psychologist said that the only way out is ahead and the choice is whether to cringe from it or to affirm it. To be able to continue this lifetime journey and to make it manageable and productive, bereaved parents must move ahead and affirm this loss while also affirming their own lives.

Eventually, time will cease to stand still for these parents. Painful and terrible moments will still occur-striking, poignant, but in some ways comforting, reminders of the child who died. There will also be regrets for experiences that were never shared. But at some unknown and even unexpected point, these parents will come to realize that there can be good moments, even happy and beautiful moments, and it will not seem impossible or wrong to smile or laugh, but it will seem right and beautiful and a fitting way to honor and remember the child who died. One day, bereaved parents may come to be "surprised by joy" (Moffat 1992, xxvii).

But in time... nature takes care of it; the waves of pain lose intensity a little and come less frequently. Then friends and relatives say the parents are getting over it, and that time heals all wounds. The parents themselves say that as the pain lessens, they begin to have energy for people and things outside themselves...This is a decision parents say [they] must make to live as well as they can in [their] new world... They can come to be happy, but never as happy. Their perspective on this and everything has changed. Their child's death is the reason for this and is a measure of the depth and breadth of the bond between parent and child. - FINKBEINER 1996,12, 20, 22, 23

References

Arnold, J.H. and P.B. Gemma. A Child Dies: A Portrait of Family Grief. Rockville, MD: Aspen Systems Corporation. 1983.
Arnold, J.H. and P.B. Gemma. A Child Dies: A Portrait of Family Grief. Philadelphia, PA: The Charles Press Publishers. Second Edition. 1994.
Bramblett, J. When Good-bye Is Forever: Learning to Live Again After the Loss of a Child. New York: Ballantine Books. 1991.
Cordell, A.S. and N. Thomas. "Fathers and Grieving: Coping with Infant Death. Journal of Perinatology, Vol. X, No. 1, March 1990.
Corr, C.A., H. Fuller, C.A. Barnickol, and D. M. Corr (Eds.). Sudden Infant Death Syndrome: Who Can Help and How. New York: Springer Publishing Company, Inc. 1991.
DeFrain, J., L. Ernst, D. Jakub, and J. Taylor. Sudden Infant Death Syndrome: Enduring the Loss. Lexington, MA: Lexington Books. 1991.
Donnelly, K. F. Recovering From the Loss of a Child. New York: Macmillan Publishing Co. 1982.
Finkbeiner, A. K. After the Death of a Child: Living with Loss Through the Years. New York: Simon and Shuster Inc. 1996.
Horchler J. N. and R.R. Morris. The SIDS Survival Guide: Information and Comfort for Grieving Family and Friends and Professionals Who Seek to Help Them. Hyattsville, MD: SIDS Educational Services. 1994.
Hosford, C. Fact Sheet: When a Twin Dies. Baltimore, MD: Maryland SIDS Information and Counseling Program. 1994.
Moffat, M.J. (Ed.) In the Midst of Winter: Selections from the Literature of Mourning. New York: Random House. 1992.
Neugeboren, J. An Orphan's Tale. New York: Holt, Rinehart & Winston. 1976.
Rando, T.A. (Ed.) Parental Loss of a Child. Champaign, IL: Research Press Company. 1986.
Schiff, H.S. The Bereaved Parent. New York: Penguin Books. 1977.
Staudacher.C. Men and Grief: A Guide for Men Surviving the Death of a Loved One, A Resource for Caregivers and Mental Health Professionals. Oak-land, CA: New Harbinger Publications, Inc. 1991.
Wisconsin Perspectives Newsletter. Milwaukee, WI: Wisconsin Sudden Infant Death Center, Spring 1989.
Wisconsin Perspectives Newsletter. Milwaukee, WI: Wisconsin Sudden Infant Death Center, December 1996.
Wisconsin Perspectives Newsletter. Milwaukee, WI: Wisconsin Sudden Infant Death Center, February 1997.

Acknowledgments

Staff of the National SIDS Resource Center (NSRC) collaborated in the preparation of this publication. We have tried to express our own thoughts and ideas, but most especially, we have drawn from our experiences with bereaved parents, whether in person, by phone, or from their own writings and reflections. We have learned from these parents, and we would like to share what we have learned with others.
We hope that this publication will help our readers better understand the magnitude of parental grief and its aftermath. We also hope that we may help others hear what grieving parents mean when they speak about "the crying of their souls."

We are deeply grateful to the many parents and caregivers who have been willing to share such sensitive and personal reflections with others. We have freely quoted from them and acknowledged each source whenever it was identified. A few citations remain anonymous because we were not able to identify their source.

NSRC staff also wish to thank the following two individuals who graciously offered their comments and suggestions and from whose publications we have quoted liberally:

Joan H. Arnold, PhD, RN
Associate Professor, College of New Rochelle, School of Nursing; Consultant to the New York City Information and Counseling Program for Sudden Infant Death Syndrome; and coauthor with Penelope B. Gemma of A Child Dies: A Portrait of Family Grief.

Joani N. Horchler
SIDS Parent; Executive Director of SIDS Educational Services Inc., Hyattsville, MD; and coauthor with Robin R. Morris of The SIDS Survival Guide: Information and Comfort for Grieving Family & Friends & Professionals Who Seek to Help Them.
Source: National SIDS Resource Center

September 1997

Page last modified or reviewed on January 23, 2014

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:

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.

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.

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

Reviewed by athealth on February 8, 2014.