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What is a reading disorder?

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

What signs are associated with a reading disorder?

Signs associated with reading disorder include:

• poor recognition of the written word
• very slow oral reading
• many mistakes in oral reading
• very poor comprehension of what has been read

Students who suffer from this kind of learning disorder frequently have:

• low self-esteem
• social problems
• increased dropout rate at school

Reading disorders may also be associated with:

• conduct disorder
• ADHD and ADD
• depression
• other learning disorders

Are there genetic factors associated with a reading disorder?

Reading disorders tend to show up more in certain families.

At what age does a reading disorder appear?

Reading disorder is usually brought to the attention of the child's parents in kindergarten or first grade when reading instruction becomes a very important part of the classroom teaching.

How often is a reading disorder seen in our society?

Although it is difficult to determine exactly, at least five percent (5%) of children in the United States suffer from a reading disorder.

How is a reading disorder diagnosed?

The person with normal intelligence demonstrates poor reading skills and no other neurological, visual, or hearing problems. Some children with very high intelligence may not have a reading disorder discovered until later in elementary school.

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

How is a reading disorder treated?

The treatment for reading disorder mainly involves putting the student into a program with an emphasis on remedial or corrective reading instruction. Usually the extra help in reading is supplied to the student through reading resource classrooms in school, small class size, or individual tutoring.

What happens to someone with a reading disorder?

With or without treatment, the reading disorder will gradually improve. However, even when good help is available to the student, the person may have chronic problems with reading. Students with high intelligence tend to improve the most.

What can people do if they need help?

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

Developed by John L. Miller, MD

Reviewed by athealth on February 7, 2014.

Why Step Relationships Aren't Easy

When two people remarry with one or both having children, they must double up their adjustment. They do not have the luxury of simply marrying as partners. They must commit to the complexity of learning to marry as parents, too. This parental dimension to their union requires additional communication as they not only work out how to function as a couple, but as a family, as well.

If they want to keep their marriage together, they must keep their parenting together. They must never allow the child to become divisive of the marriage - to cause them to feel they are on opposing sides in the parental relationship. They must always stay on the same side with both of them wanting to support dialogue and decisions that preserve the union they have created. "We really see this situation differently, and that's okay. Let's talk until we understand each other's point of view and work out a position we can both support."

The Entry Adjustment

Before remarriage, honeymoon harmony may have reigned among them all, with everyone on his/her best behavior, playing together but not living together. However, once they actually form a blended family unit, the easy-going shine quickly wears off, and hard reality sets in. Now, differences between stepparent and stepchildren over household conduct, between parent and stepparent over child raising, between parent and children over respect for the new marriage, begin to irritate family relationships, causing conflicts as incompatibilities become hard to deny and harder to accept.

• "Your kids never pick anything up!"
• "Our stepparent is a neat freak!"
• "You care more about your new marriage than you do for us!"
• "Who comes first, your kids or me?"
• "Why can't you both just get along for my sake?"

Complaints, complaints! Unhappily, the couple may wonder: "Why can't everyone just enjoy each other's company?" That's a good question. Knowing some of the answers allows the couple to develop realistic expectations and make effective choices that can help remarriage with children work.

Adjustment to Parental Remarriage

It can frustrate a remarried mother or father to have a child whose discontent threatens to spoil the happiness that parent seeks. "Why must you make things so difficult at a time when I want everything to go well?" At this point it is worth remembering that remarriage is an adult decision, selfishly made, at least for one of the parents, for his or her personal happiness. Like divorce, it is not a decision either made by the child or for the child's sake. And, it is not a decision that necessarily pleases the child who may feel jerked around by family changes over which he or she had no control. "I liked things better living with my parent alone, and I still miss having Mom and Dad and us all together." Divorce and remarriage both create a powerful conflict of interest between parent and child. These family changes are chosen to advance happiness of the parent, to some degree at the child's felt expense.

Being Taken Through One's Parents' Changes

The transition from parental marriage to parental divorce to parental remarriage creates a host of changes for the child to accept.

• Divorce ends living all together in the original family and creates separate households, while remarriage means learning to live on daily intimacy with a step parent whose ways are unfamiliar and who is in many ways a stranger. "It feels awkward living with some adult I hardly know."
• Divorce and remarriage also alters caring. In the original family caring felt unconditional; then divorce questioned the constancy of caring (as parents lost love for each other); and, now, in remarriage caring from and for the step parent can feel conditional. "We like each other when we get along, and we don't like each other when we don't."
• In the original family, both parents were fully there; divorce meant one parent was always gone; and with remarriage the resident parent is only partly there. "I get less time with my parent now that my stepparent is here."
• In the original family, the child assumed the parents would always be together; divorce meant accepting they would never be together again; remarriage means parent and stepparent will be together for the foreseeable future. "First they tear up the old family, then they expect me to get used to a new one!"
• In the original family, parents were the same as the child had always known them; with freedom from divorce each parent starts making personal changes; and with remarriage the influence of the stepparent changes how the mother or father has always parented. "What I hate most about your remarriage is the way you've changed!"

And these are just some of the adjustments a child must make.

Attachment Expectations

One particular area of adjustment about which there can be unrealistic parental expectations is concerning the child's attachment to the parent's new partner. Central to the dream of a happy remarriage may be the dream of a loving bond between child and stepparent. Chances for this to occur are largely dependent on how old the child is at the time of parental remarriage. The watershed age when acceptance tends to become harder is the onset of early adolescence, around years nine or ten, when the developmental separation from childhood commonly begins. Below that age, significant attachment is more likely to occur; but above that age, adolescence makes bonding much more difficult.

Divorce and remarriage tend to intensify the natural grievance and rebellion of adolescence. Sense of injury and being treated unfairly by disruptive family change can fuel the young person's anger. The stepparent is an easy target for this resentment since in this relationship there is no history of love so there's no love to lose. Now the stepparent/stepchild relationship is easily inflamed by mutual blame, each one scapegoating and stereotyping the other for what is wrong in the family, pitting the "evil" stepparent who is always "mean and moody" against the "no good kid" who is " bad mannered and uncooperative."

To prevent these stereotypes from taking hold, rather than stepparent and stepchild having less to do with each other (which is what they want), they actually need more time alone together to allow contact to inform their judgments with knowledge, and not allow separation to reinforce their prejudices with ignorance.

Realistic Expectations for the Step Relationship

A parent's realistic expectations for attachment between stepparent and stepchild when that child is in adolescence are these. It is realistic for the parent to expect, and insist, that the teenager treat the stepparent with respect, even when that young person wishes this outside adult could just go away. It is realistic for the parent to expect the stepparent to care about what happen to the stepchild even when the stepparent does not at the moment much care for the stepchild's attitude or behavior.

It is also realistic to expect that many of the differences the stepparent brings into the family -- of sex role definition, of personality, of skills, of knowledge, of interests -- can all be turned to positive value for the stepchild when they create an opportunity to learn and grow and profit from this association. This is not to recommend divorce and remarriage, but increased diversity of family life is not simply a cause for divisiveness, it is a source of additional richness as well. To encourage taking advantage of this positive side, it helps if the stepparent clarifies that he or she is not in any way competing with, or trying to supplant, the absent biological parent. "I'm not your real parent and have no desire to be. But I am your real stepparent, and exactly what that means is something you and I will have to work out together. Hopefully, we can make it into a relationship we can both enjoy."

Dealing With Step Family Differences

Step relationships mix people up by increasing the mix of individual differences in a family. These differences are often incompatible and make accommodating and fitting in hard to do. When two cultures come together for the first time, some clashes are bound to occur. "Whose way is the right way?" is the common denominator for many conflicts as stepparent and parent (plus children) work out on whose terms they will live, which way of family life will prevail. The outcome is always some mix of the two, each side in the partnership giving up more traditional practices and tolerating more change than was originally anticipated. "I never thought I'd learn to live this way!" From "my way" and from "your way" the couple comes to define "our way," and the stepfamily starts creating a cultural identity of its own.

From the outset of remarried life, there will be stepchild behavior and parenting practices that seem acceptable to the parent, but are offensive to the stepparent. "How can you let them act like that? Why haven't you taught them any better?" And immediately the parent feels put on the spot. "There's nothing wrong with their behavior, you're just not used to normal kids!"

In remarriage, stepchildren come to represent the cultural divide between parent and stepparent. To attack child raising differences by attacking each other, arguing over who is right and who is wrong, will not serve the new marriage partners well. It will only polarize and antagonize their relationship. Parent and stepparent will never see the children through the same perceptual lens. Typically, the parent sees the child more affirmatively ("He is really trying!"), and the stepparent sees the child more critically ("He is not trying hard enough!"). The parent (attached and approving) tends to see the glass (the child) as half-full, and the stepparent (fatigued and frustrated) tends to see the glass as half empty. Parent and stepparent need to turn their contrasting perspectives to advantage.

What the parent has to offer is constancy and acceptance. "Loving who they are is always more important to me than always liking how they act." What the stepparent has to offer is distance and perspective. "Sometimes I can see what your kids need more objectively than you can." It is this mix of parental acceptance and stepparent perspective that can be combined to great advantage, depth of caring and breadth of vision both contributing the children's well being. Love can blind the parent to problems the stepparent is willing to see. Frustration can cause the stepparent to give up on the child to whom the parent remains loyally committed.

The Discussion Contract

In their discussions over the children, it helps enormously if parent and stepparent agree to the following contractual exchange. When an issue over the stepchild's behavior arises, the stepparent will express that concern to the parent with utmost tact, not putting the parent on the defensive by voicing complaints, comparisons, or criticism. Instead, communication is kept as objective and non-evaluative as possible. "I don't agree with how your child is choosing to act, and I would like to talk with you about trying to change that behavior." In return, the parent will be continually mindful of the stepparent's efforts to help create a family for the stepchild, expressing this partner's appreciation to the stepparent for hanging in there with a child not his or her own. The stepparent needs appreciation because the stepchild is not likely to give it. And the parent needs tact because it is so easy to feel defensive on one's child's behalf.

Role Pressures

In addition, it helps for each partner to be sensitive to stepfamily pressures that complicate each other's role. To be the parent in the remarried family often means feeling torn apart by conflicting loyalties and sympathies, caught in the middle between two loved ones who sometimes can't stand each other, each coming to the parent/partner to confide complaints. Of course, the good part of being in the middle is getting twice as much love as either of the two occasional antagonists. How much of the conflict between spouse and child to mediate and how much to let them just work out is an ongoing dilemma. In general, the more stepparent and stepchild are allowed to work out their differences directly, the less often the parent will intervene and feel caught in the painful middle. One approach that usually helps is for stepparent and stepchild to have some times with just the two of them together without the parent present. In this situation there is no parent time and attention to vie for, so each is usually more open to finding ways to get along.

To be the stepparent is to feel continually affronted by parenting values and stepchild behavior that seem unacceptable, to wonder whether to speak up or not, or to make an invisible effort to get along by shutting up about a lot. "Swallowing offenses" is how one stepfather described it. Since these efforts at tolerance and restraint are not seen by anyone else, they are not credited as effort, hence the problem of invisibility. In addition, there is often the frustration of being discounted by the stepchild who ignores the stepparent's presence and opinions, treating the parent as the only adult in the family who matters, the only adult worth talking to or seeking out for companionship. If this dismissive conduct is going on, the parent can insist on more respectful treatment. "I expect you to treat your stepparent with the same courtesy and respect that we give you."

These are the pains that come with the two roles. The parent often feels caught in the middle, unable to do right by one loved one without doing wrong in the eyes of the other. The stepparent often feels like an invisible and discounted family member whose efforts at adjustment, tolerance, and restraint are unseen and unappreciated. For the sake of the marriage, the parent can recognize the stepparent's efforts, thereby reducing discomfort from invisibility, and the stepparent can work out differences with the stepchild without pulling the parent into the middle.

Time for the Marriage

Finally, there is the abiding importance of parent and stepparent making and taking sufficient time alone and apart to shed parental roles and concerns and just enjoy being together as partners. Becoming life partners is the primary reason why they got together in the first place.

And, when they are back into parental role, the parent can explain how there is not one but two ways he or she experiences the stepparent's love. "When you treat me as your loving partner, and when you treat my children with love, in both ways do I experience your love for me." To which the stepparent can reply: "When you love me as your partner and as co-parent of your children, in both ways do I experience your love for me." Remarriage with stepchildren is at least twice as hard as marriage with mutual children or with none, but well done, it can be twice as rewarding, too.

About the Author

Carl E. Pickhardt, PhD, is the author of numerous articles and books on parenting, including The Connected Father: Understanding Your Unique Role and Responsibilities During Your Child Adolescence; Keys To Developing Your Child's Self-Esteem; and The Future of Your Only Child: How to Guide Your Child to a Happy and Successful Life to be published in 2008. His books are available at amazon.com.

© Carl Pickhardt, PhD, 2003 Used with permission.
Page last modified or reviewed on January 24, 2014

Terms You Need to Know

Dementia is a medical condition that interferes with the way the brain works. Symptoms include anxiety, paranoia, personality changes, lack of initiative, and difficulty acquiring new skills. Besides Alzheimer's disease, some other types or causes of dementia include alcoholic dementia, depression, delirium, HIV/AIDS-related dementia, Huntington's disease (a disorder of the nervous system), inflammatory disease (for example, syphilis), vascular dementia (blood vessel disease in the brain), tumors, and Parkinson's disease.

Alzheimer's disease is the most common form of dementia. It proceeds in stages over months or years and gradually destroys memory, reason, judgment, language, and eventually the ability to carry out even simple tasks.

Delirium is a state of temporary but acute mental confusion that comes on suddenly. Symptoms may include anxiety, disorientation, tremors, hallucinations, delusions, and incoherence. Delirium can occur in older persons who have short-term illnesses, heart or lung disease, long-term infections, poor nutrition, or hormone disorders. Alcohol or drugs (including medications) also may cause confusion.

Delirium may be life-threatening and requires immediate medical attention.

Depression can occur in older persons, especially those with physical problems. Symptoms include sadness, inactivity, difficulty thinking and concentrating, and feelings of despair. Depressed persons often have trouble sleeping, changes in appetite, fatigue, and agitation. Depression usually can be treated successfully.

Purpose of this Booklet

This booklet is about Alzheimer's disease and other types of dementia. It presents information for patients, family members, and other caregivers. It talks about the effects Alzheimer's disease can have on you, your family members, and your friends.

The booklet describes the early signs and symptoms of Alzheimer's disease. Sources of medical, social, and financial support are listed in the back of the booklet. This booklet is not about treating Alzheimer's disease.

What Is Alzheimer's Disease?

In Alzheimer's disease and other dementias, problems with memory, judgment, and thought processes make it hard for a person to work and take part in day-to-day family and social life. Changes in mood and personality also may occur. These changes can result in loss of self-control and other problems.

Some 2 to 4 million persons have dementia associated with aging. Of these individuals, as many as two-thirds have Alzheimer's disease.

Although there is no cure for Alzheimer's disease at this time, it may be possible to relieve some of the symptoms, such as wandering and incontinence.

The earlier the diagnosis, the more likely your symptoms will respond to treatment. Talk to your doctor as soon as possible if you think you or a family member may have signs of Alzheimer's disease.

Research is under way to find better ways to treat Alzheimer's disease. Ask your doctor if there are any new developments that might help you.

Who Is Affected?

The chances of getting Alzheimer's disease increase with age. It usually occurs after age 65. Most people are not affected even at advanced ages. There are only two definite factors that increase the risk for Alzheimer's disease: a family history of dementia and Down syndrome.

Family History of Dementia

Some forms of Alzheimer's disease are inherited. If Alzheimer's disease has occurred in your family members, other members are more likely to develop it. Discuss any family history of dementia with your family doctor.

Down Syndrome

Persons with Down syndrome have a higher chance of getting Alzheimer's disease. Close relatives of persons with Down syndrome also may be at risk.

What Are the Signs of Alzheimer's Disease?

The classic sign of early Alzheimer's disease is gradual loss of short-term memory. Other signs include:

• Problems finding or speaking the right word.
• Inability to recognize objects.
• Forgetting how to use simple, ordinary things, such as a pencil.
• Forgetting to turn off the stove, close windows, or lock doors.

Mood and personality changes also may occur. Agitation, problems with memory, and poor judgment may cause unusual behavior. These symptoms vary from one person to the next.

Symptoms appear gradually in persons with Alzheimer's disease but may progress more slowly in some persons than in others. In other forms of dementia, symptoms may appear suddenly or may come and go.

If you have some of these signs, this does not mean you have Alzheimer's disease. Anyone can have a lapse of memory or show poor judgment now and then. When such lapses become frequent or dangerous, however, you should tell your doctor about them immediately.

Possible Signs of Alzheimer's Disease

Do you have problems with any of these activities?

• Learning and remembering new information.

  Do you repeat things that you say or do? Forget conversations or appointments? Forget where you put things?

• Handling complex tasks.

  Do you have trouble performing tasks that require many steps such as balancing a checkbook or cooking a meal?

• Reasoning ability.

  Do you have trouble solving everyday problems at work or home, such as knowing what to do if the bathroom is flooded?

• Spatial ability and orientation.

  Do you have trouble driving or finding your way around familiar places?

• Language.

  Do you have trouble finding the words to express what you want to say?

• Behavior.

  Do you have trouble paying attention? Are you more irritable or less trusting than usual?

Remember, everyone has occasional memory lapses. Just because you can't recall where you put the car keys doesn't mean you have Alzheimer's disease.

Consulting the Doctor

Identifying mild cases of Alzheimer's disease can be very difficult. Your doctor will review your health and mental status, both past and present. Changes from your previous, usual mental and physical functioning are especially important.

Persons with Alzheimer's disease may not realize the severity of their condition. Your doctor will probably want to talk with family members or a close friend about their impressions of your condition.

The doctor's first assessment for Alzheimer's disease should include a focused history, a physical examination, a functional status assessment, and a mental status assessment.

Medical and Family History

Questions the doctor may ask in taking your history include: How and when did problems begin? Have the symptoms progressed in steps or worsened steadily? Do they vary from day to day? How long have they lasted?

Your doctor will ask about past and current medical problems and whether other family members have had Alzheimer's disease or another form of dementia.

Education and other cultural factors can make a difference in how you will do on mental ability tests. Language problems (for example, difficulty speaking English) can cause misunderstanding. Be sure to tell the doctor about any language problems that could affect your test results.

It is important to tell the doctor about all the drugs you take and how long you have been taking them. Drug reactions can cause dementia. Bring all medication bottles and pills to the appointment with your doctor.

Do you take any medications? Even over-the-counter drugs, eye drops, and alcohol can cause a decline in mental ability. Tell your doctor about all the drugs you take. Ask if the drugs are safe when taken together.

Physical Examination

A physical examination can determine whether medical problems may be causing symptoms of dementia. This is important because prompt treatment may relieve some symptoms.

Functional Status Assessment

The doctor may ask you questions about your ability to live alone. Sometimes, a family member or close friend may be asked how well you can do activities like these:

• Write checks, pay bills, or balance a checkbook.
• Shop alone for clothing, food, and household needs.
• Play a game of skill or work on a hobby.
• Heat water, make coffee, and turn off the stove.
• Pay attention to, understand, and discuss a TV show, book, or magazine.
• Remember appointments, family occasions, holidays, and medications.
• Travel out of the neighborhood, drive, or use public transportation.

Sometimes a family member or friend is not available to answer such questions. Then, the doctor may ask you to perform a series of tasks ("performance testing").

Mental Status Assessment

Several other tests may be used to assess your mental status. These tests usually have only a few simple questions. They test mental functioning, including orientation, attention, memory, and language skills. Age, educational level, and cultural influences may affect how you perform on mental status tests. Your doctor will consider these factors in interpreting test results.

Alzheimer's disease affects two major types of abilities:

• The ability to carry out everyday activities such as bathing, dressing, using the toilet, eating, and walking.
• The ability to perform more complex tasks such as using the telephone, managing finances, driving a car, planning meals, and working in a job. When a person has Alzheimer's disease, problems with complex tasks appear first and over time progress to more simple activities.

Treatable Causes of Dementia

Sometimes the physical examination reveals a condition that can be treated. Symptoms may respond to early treatment when they are caused by:

• Medication (including over-the- counter drugs).
• Alcohol.
• Delirium.
• Depression.
• Tumors.
• Problems with the heart, lungs, or blood vessels.
• Metabolic disorders (such as thyroid problems).
• Head injury.
• Infection.
• Vision or hearing problems.

Drug reactions are the most common cause of treatable symptoms. Older persons may have reactions when they take certain medications. Some medications should not be taken together. Sometimes, adjusting the dose can improve symptoms.

Delirium and depression may be mistaken for or occur with Alzheimer's disease. These conditions require prompt treatment. See the inside front cover of this booklet for more information on delirium and depression.

Special Tests

Gathering as much information as possible will help your doctor diagnose early Alzheimer's disease while the condition is mild. You may be referred to other specialists for further testing.

Some special tests can show a person's mental strengths and weaknesses and detect differences between mild, moderate, and severe impairment. Tests also can tell the difference between changes due to normal aging and those caused by Alzheimer's disease.

If you go to a special doctor for these tests, he or she should return all test results to your regular family doctor. The results will help your doctor track the progress of your condition, prescribe treatment, and monitor treatment effects.

Getting the Right Care

When the diagnosis is Alzheimer's disease, you and your family members have serious issues to consider. Talk with your doctor about what to expect in the near future and later on, as your condition progresses. Getting help early will help ensure that you get the care that is best for you.

When tests do not indicate Alzheimer's disease, but your symptoms continue or worsen, check back with your doctor. More tests may be needed. If you still have concerns, even though your doctor says you do not have Alzheimer's disease, you may want to get a second opinion.

Whatever the diagnosis, followup is important.

Report any changes in your symptoms. Ask the doctor what followup is right for you. Your doctor should keep the results of the first round of tests for later use. After treatment of other health problems, new tests may show a change in your condition.

Recognizing Alzheimer's disease in its early stages, when treatment may relieve mild symptoms, gives you time to adjust. During this time, you and your family can make financial, legal, and medical plans for the future.

Coordinating Care

Your health care team may include your family doctor and medical specialists such as psychiatrists or neurologists, psychologists, therapists, nurses, social workers, and counselors. They can work together to help you understand your condition, suggest memory aids, and tell you and your family about ways you can stay independent as long as possible.

Talk with your doctors about activities that could be dangerous for you or others, such as driving or cooking. Explore different ways to do things.

Telling Family and Friends

Ask your doctor for help in telling people who need to know that you have Alzheimer's disease &emdash; members of your family, friends, and coworkers, for example.

Alzheimer's disease is stressful for you and your family. You and your caregiver will need support from others. Working together eases the stress on everyone.

Where To Get Help?

Learning that you have Alzheimer's disease can be very hard to deal with. It is important to share your feelings with family and friends.

Many kinds of help are available for persons with Alzheimer's disease, their families, and caregivers. Turn to the back of this booklet for a list of resources for patients and families. These resources include:

• Support groups.
  Sometimes it helps to talk things over with other people and families who are coping with Alzheimer's disease. Families and friends of people with Alzheimer's disease have formed support groups. The Alzheimer's Association has active groups across the country. Many hospitals also sponsor education programs and support groups to help patients and families.
• Financial and medical planning.
  Time to plan can be a major benefit of identifying Alzheimer's disease early. You and your family will need to decide where you will live and who will provide help and care when you need them.
• Legal matters.
  It is also important to think about certain legal matters. An attorney can give you legal advice and help you and your family make plans for the future. A special document called an advance directive lets others know what you would like them to do if you become unable to think clearly or speak for yourself.

Other Booklets Are Available

The information in this booklet is based on Recognition and Initial Assessment of Alzheimer's Disease and Related Dementias: Clinical Practice Guideline No. 19. A multidisciplinary panel of physicians, psychiatrists, psychologists, neurologists, nurses, a geriatrician, a social worker, and two consumer representatives developed the guideline. The Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Department of Health and Human Services, supported its development. Other AHCPR guidelines may be helpful to families affected by Alzheimer's disease. They include the following:

• Depression Is a Treatable Illness: Patient Guide discusses major depressive disorder, which usually can be treated successfully with the help of a health professional. (AHCPR Publication No. 93-0053)
• Recovering After a Stroke: Patient and Family Guide tells how to help a person who has had a stroke achieve the best possible recovery. (AHCPR Publication No. 95-0664)
• Understanding Urinary Incontinence in Adults: Patient Guide describes why people lose urine when they don't want to and what can be done about it. (AHCPR Publication No. 96-0684)
• Preventing Pressure Ulcers: Patient Guide discusses symptoms and causes of bed sores and ways to prevent them. (AHCPR Publication No. 92-0048)
• Treating Pressure Sores: Consumer Guide describes basic steps of care for bed sores. (AHCPR Publication No. 95-0654)

For more information on these or other guidelines, or to receive more copies of this booklet, call toll-free: 800-358-9295. Or write to:Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907

Source: Agency for Healthcare Research and Quality

AHCPR Publication No. 96-0704

Page last modified or reviewed by athealth.com on February 4, 2014

How Are They Related?

Eating disorders and obesity are usually seen as very different problems but actually share many similarities. In fact, eating disorders, obesity, and other weight-related disorders may overlap as girls move from one problem, such as unhealthy dieting, to another, such as obesity. This information sheet is designed to help parents, other adult caregivers, and school personnel better understand the links between eating disorders and obesity so they can promote healthy attitudes and behaviors related to weight and eating.

How are eating disorders and obesity related?

Eating disorders and obesity are part of a range of weight-related problems.

These problems include anorexia nervosa, bulimia nervosa, anorexic and bulimic behaviors, unhealthy dieting practices, binge eating disorder, and obesity. Adolescent girls may suffer from more than one disorder or may progress from one problem to another at varying degrees of severity. It is important to understand this range of weightrelated problems in order to avoid causing one disorder, such as bulimia, while trying to prevent another, such as obesity.¹

Body dissatisfaction and unhealthy dieting practices are linked to the development of eating disorders, obesity, and other problems.

High numbers of adolescent girls are reporting that they are dissatisfied with their bodies and are trying to lose weight in unhealthy ways, including skipping meals, fasting, and using tobacco. A smaller number of girls are even resorting to more extreme methods such as self-induced vomiting, diet pills, and laxative use.²

These attitudes and behaviors place girls at a greater risk for eating disorders, obesity, poor nutrition, growth impairments, and emotional problems such as depression.³ Research shows, for example, that overweight girls are more concerned about their weight, more dissatisfied with their bodies, and more likely to diet than their normal-weight peers.⁴

Binge eating is common among people with eating disorders and people who are obese.

People with bulimia binge eat and then purge by vomiting, using laxatives, or other means. Binge eating that is not followed by purging may also be considered an eating disorder and can lead to weight gain. More than one-third of obese individuals in weight-loss treatment programs report difficulties with binge eating.⁵ This type of eating behavior contributes to feelings of shame, loneliness, poor self-esteem, and depression.⁶ Conversely, these kinds of feelings can cause binge eating problems.⁷ A person may binge or overeat for emotional reasons, including stress, depression, and anxiety.⁸

Depression, anxiety, and other mood disorders are associated with both eating disorders and obesity.

Adolescents who are depressed may be at an increased risk of becoming obese. One recent study found that depressed adolescents were two times more likely to become obese at the one year follow up than teens who did not suffer from depression.⁹ In addition, many people with eating disorders suffer from clinical depression, anxiety, personality or substance abuse disorders, or in some cases obsessive compulsive disorder.¹⁰ Therefore, a mental health professional may need to be involved in treating an adolescent who is obese or suffers from an eating disorder or other weight-related problem.

The environment may contribute to both eating disorders and obesity.

The mass media, family, and peers may be sending children and adolescents mixed messages about food and weight that encourage disordered eating.¹¹ Today's society idealizes thinness and stigmatizes fatness, yet high-calorie foods are widely available and heavily advertised.¹² At the same time, levels of physical activity are at record lows as television and computers replace more active leisure activities, travel by automobile has replaced walking, and many communities lack space for walking and recreation.¹³

Most teens don't suffer from either anorexia or obesity. They are more likely to engage in disordered eating behaviors such as bingeing, purging, and dieting. These behaviors are associated with serious physical and emotional health problems. We've got to get back to three square meals a day, healthy meal planning, nutritious snacks, and regular physical activity.¹⁴
- Richard Kreipe, MD, Chief, Division of Adolescent Medicine, University of Rochester Medical Center

Health Risks

Eating disorders may lead to

• Stunted growth
• Delayed menstruation
• Damage to vital organs such as the heart and brain
• Nutritional deficiencies, including starvation
• Cardiac arrest
• Emotional problems such as depression and anxiety

Obesity increases the risk for

• High blood pressure
• Stroke
• Cardiovascular disease
• Gallbladder disease
• Diabetes
• Respiratory problems
• Arthritis
• Cancer
• Emotional problems such as depression and anxiety

Definitions

Body image is how you see yourself when you look in the mirror or picture yourself in your mind.

Obesity means having an abnormally high proportion of body fat. A person is considered obese if he or she has a body mass index (BMI) of 30 or greater. BMI is calculated by dividing a person's weight in kilograms by height in meters squared. You can also calculate your BMI by going to an online BMI calculator at www.fns.usda.gov/tnrockyrun/diff.htm.

Overweight refers to an excess of body weight compared to set standards. The excess weight may come from muscle, bone, fat, and/or body water. A person can be overweight without being obese (for example, athletes who have a lot of muscle). However, many people who are overweight are considered obese due to excess fat on their bodies. A person may be considered overweight if he or she has a BMI of 25-29.9.

Anorexia nervosa is self-starvation. People with this disorder eat very little even though they are thin. They have an intense and overpowering fear of body fat and weight gain.

Bulimia nervosa is characterized by cycles of binge eating and purging, either by vomiting or taking laxatives or diuretics (water pills). People with bulimia have a fear of body fat even though their size and weight may be normal.

Binge eating disorder means eating large amounts of food in a short period of time, usually alone, without being able to stop when full. The overeating and bingeing are often accompanied by feeling out of control and followed by feelings of depression, guilt, or disgust.

Disordered eating refers to troublesome eating behaviors, such as restrictive dieting, bingeing, or purging, which occur less frequently or are less severe than those required to meet the full criteria for the diagnosis of an eating disorder.

End Notes

1 Neumark-Sztainer, D. Obesity and Eating Disorder Prevention: An Integrated Approach. Adolescent Medicine, Feb;14(1):159-73 (Review), 2003.

2 Neumark-Sztainer, D., Story, M., Hannan, P.J., et al. Weight-Related Concerns and Behaviors Among Overweight and Non-Overweight Adolescents: Implications for Preventing Weight-Related Disorders. Archives of Pediatrics and Adolescent Medicine, Feb;156(2):171-8, 2002.

3 Neumark-Sztainer, D. Obesity and Eating Disorder Prevention: An Integrated Approach. 2003.

4 Burrows, A., Cooper, M. Possible Risk Factors in the Development of Eating Disorders in Overweight Pre-Adolescent Girls. International Journal of Obesity and Related Metabolic Disorders, Sept;26(9):1268-1273, 2002; Davison, K.K., Markey, C.N., Birch, L.L. Etiology of Body Dissatisfaction and Weight Concerns Among 5-year-old Girls. Appetite, Oct;35(2):143-151, 2000; Vander Wal, J.S., Thelen, M.H. Eating and Body Image Concerns Among Obese and Average-Weight Children. Addictive Behavior, Sep-Oct;25(5):775-778, 2000.

5 Yanovski, S.Z. Binge Eating in Obese Persons. In Fairburn, C.G., Brownell, K.D. (eds), Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 403-407, 2002.

6 Waller, G. The Psychology of Binge Eating. In Fairburn, C.G., Brownell, K.D. (eds) Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 98-102, 2002.

7 Fairburn, C., Overcoming Binge Eating. New York: The Guilford Press, 1995, pp. 80-99.

8 Goodman, E, Whitaker, R. A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity. Pediatrics. 2002 Sep;110(3):497-504. Lumeng JC, Gannon K, Cabral HJ, Frank DA, Zuckerman B. Association between clinically meaningful behavior problems and overweight in children. Pediatrics. 2003 Nov;112(5):1138-45.

9 Goodman, E., Whitaker, R.C. A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity. Pediatrics. Sep;110(3):497-504, 2002.

10 National Mental Health Association. Teen Eating Disorders. 1997.

11 Irving, L.M., Neumark-Sztainer, D. Integrating the Prevention of Eating Disorders and Obesity: Feasible or Futile. Preventive Medicine, 34:299-309, 2002. Stice, E. Sociocultural Influences on Body Image and Eating Disturbance. In Fairburn, C.G., Brownell, K.D. (eds) Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 103-107, 2002.

12 Battle, E.K., Brownell, K.D. Confronting a Rising Tide of Eating Disorders and Obesity: Treatment vs. Prevention and Policy. Addictive Behavior, 21:755-65 (Review), 1996.

13 French, S.A, Story, M., Jeffery, R. Environmental Influences on Eating and Physical Activity. Annual Review of Public Health, 22:309-35 (Review), 2001.

14 Kreipe, R. Personal communication. November 9, 2003.

Adapted from Eating Disorders and Obesity Companion Piece
U.S. Department of Health and Human Services Office on Women's Health.

Page last modified or reviewed by athealth.com on February 4, 2014

When we hear the terms "discipline" and "father," there appears to be a natural connection, but often with negative overtones. The idea of a father as one who punishes or is an authoritarian figure runs deep in our culture. Yet, fathers have much more to offer than only helping their children learn self- control and social rules, and their role involves much more than punishment.

Discipline is one of those familiar words that carry different meanings. To many people, discipline simply implies the setting of firm rules and limits and administering punishments for breaking those rules. But, in fact, the meaning is more complex. The word discipline is based on the Latin word "discipulus," which means "a pupil," or more accurately, "one who is learning." Thus, the ancient origins of discipline are based on the notion of a reciprocal process of teaching and learning.

This notion is included in the modern definition of discipline. According to the American Heritage Dictionary (2000), the verb "to discipline" is defined as: 1. to train by instruction and practice, especially to teach self-control to. 2. to teach to obey rules or accept authority. See Synonyms at teach. 3. to punish in order to gain control of, enforce obedience. See Synonyms at punish.

When discipline refers to training and teaching specific behaviors of selfcontrol and moral development, this becomes a tall order for all parents, yet one that has historically been embraced by fathers. Indeed, prior to the 1900s in western culture, it was assumed that fathers more than mothers were responsible for the development of their children's moral behavior and self control. Men were expected to take on the critical teaching role. How can today's fathers provide discipline, in the sense of teaching and training their children? When does discipline start, and what form does it take?

Why Discipline is Important

The association between child-rearing practices and children's development of self-control has been well documented in research. Studies indicate that the quality of parental care is critical in the first year of life. Parents who are responsive, stimulating, and encouraging with their babies are laying the foundation for the development of self-control. During this first year, babies learn whether or not their signals, such as cries when hungry, or cold, are understood, and if their needs are met. A successful interaction involves a parent reacting to a baby's message and behaving responsively and leads to more successful social interactions (Parke & Sawin 1976). In the second year, when children begin walking and exploring on their own, it is important for parents to set limits for the child's safety and provide guidelines for acceptable behavior. Parents begin to think more and more about how and when to discipline their toddlers who are increasingly asserting their independence and autonomy which are necessary, normal aspects of early development.

The temperament of each young child affects each parent's approach to discipline. Research shows that fussy, active, or difficult toddlers often drive their parents to be more restrictive and more punitive (Patterson 1980). A cycle of negative interactions is set in motion; misbehavior is followed by punishment; punishment is followed by increasing, accelerating patterns of misbehavior. The father's role in these family interactions involves both the support of the mother and direct interactions with the child. Both research studies and parents themselves report that the hard-to-manage children are more compliant and agreeable with their fathers than with their mothers. Also, when the father is present in the room or nearby, children are much more compliant with their mothers (Patterson 1980; Lytton 1980). Research also indicates that when problems spiral out of control, sometimes fathers step in with harsh, direct punishment to get the situation back under control, which, unfortunately, can precipitate a cycle of punishment and misbehavior (DeKlyen 1998). Thus, poorly modulated behavior in a toddler or preschool child can overwhelm the mother or father, as well as split the parents into disagreement as they argue on how to manage the child. When parents disagree on behavior management, there is little improvement in the child.

The first positive strategy is to help the parents agree on how to handle some specific parenting issues. For example, they might come up with a plan to follow at bedtime, including specific ways to talk with the child. In this way, consistency is built up in the home environment. Calm, consistent behavior by adults is the model for teaching self-control in the child. The concept of discipline as teaching a set of behaviors to the child "not just punishment" becomes a reality only when there is consistency. A consistent plan on handling bedtime tantrums carried out by the mother and father can go a long way toward establishing a general pattern of discipline and the development of self-control.

Sidebar: Strategies for disciplining kids who have ADHD. Be clear about the expectations; consistent; patient; rather than just saying "no," explain (preferably show) the child what positive behavior you expect; reward positive behavior with attention.

Research emphasizes the important role of fathers in helping children to learn the standards of behavior for their group and to develop the capacity of self-regulation (Lamb 1987). When fathers are absent, curtail, or ignore their child-rearing responsibilities, there are implications throughout the family system. Mothers are likely to feel unsupported, abandoned, angry, and resentful. The resulting tension exacerbates the child's challenging behaviors. Lack of parental involvement by the father leaves the mother as the sole unsupported teacher of social skills and deprives the child of another role model. When fathers do not participate in child rearing, the results can be heightened intensity and duration of mother-child conflict and problems in discipline (Campbell 2002).

Playing with Children

The role of fathers for all children, not just those with challenging behaviors, is unique and important. As Lamb (1998) has indicated, the father is typically the one who engages in physical rough and tumble play with children. In the course of active play, children may test limits. Whether the activity involves tickling, wrestling or splashing in the pool, paying attention and stopping when needed are important lessons to be learned. Thus, discipline and learning self-control can start with play.

Fathers tend to be more active in their play, helping their children to be first in a race, catch the ball the most times, throw the farthest, jump the farthest, and leap into the water. While mothers are sometimes exasperated at fathers who get their sons and daughters excited, energized, and otherwise "all worked up," play has purpose. It tests limits and boundaries generally pushed less often by mothers. The children have to learn how to play without hurting someone else or getting hurt themselves, and how to direct their energy.

Constructive play is something both fathers and mothers can enjoy. Whether building with blocks to construct a road or a family's house, or "cooking" with play food and utensils, children enjoy the process of creating and constructing, then starting all over again. One of the most valuable interactions a father can have is getting down on the floor each day for 15 minutes and playing with his child - playing, commenting, and giving undivided attention.

Talking to Children

How parents speak greatly influences how often children comply with directions. While individuals certainly differ, the research is fairly consistent that mothers tend to explain more to their children, while fathers tend to use fewer words in all interactions. Fathers are often more tactile and physical, while mothers are typically more verbal and didactic (Parke 1996). Let's look at the task of giving a child the command to get ready to go to bed. Many mothers assume that if the child really understands why it is time for bed, they will be more likely to go to bed. For example, a mother might say, "Go to bed now because you have a busy day tomorrow," and follow it with a long explanation about how the body needs to rest, the child looks tired, and so on. However, the child, may lose track of the direction "go to bed" in the midst of all the other words.

On the other hand, some parents, more often fathers, tend to be a bit more direct, but often without the explanation. A very direct, "Go to bed now" appears harsh and may elicit some negative emotions from the child. An effective middle ground would be a brief explanation, followed by a clear command:" It's past your bedtime, you've had a busy day and have a lot to do tomorrow. It's time to go to bed." Repeating the direction (go to bed) at the end of the verbal exchange helps bring it to the child's attention.

Consequences: Positive and Negative

Consistently positive or negative responses to a child's behavior will change how often the child will respond the same way. Most child behavior is shaped by hundreds of daily back-and-forth interactions with the world around them, not by any single event or response. In short, parents need to do what they say, and to be consistent. If parents promise to do things and do them each time they promise, their children will trust and expect them to follow through. If a parent promises to play after dinner, and does, the child may eat more neatly and quickly. If a parent promises to take away a privilege because the child has broken a rule, the parent needs to do it so the child follows the rule next time. Promises are critically important when fathers do not live with their children and visits are arranged. Promised visits, phone calls and activities must occur, or the child learns not to trust the father, or other adults for that matter.

When positive and negative consequences are used to shape behavior, large, lavish one-time rewards of an expensive toy or video game, or harsh intense punishments such as being spanked severely or sent to one's room for hours, are not as effective as the little rewards of adult attention and time, or consistent brief mild punishments. For most children between the ages of two and six, a brief "Time Out" of sitting away quietly, not isolated, but not being paid attention is the most effective mild punishment. "Time Out" allows both parent and child to cool down, and the withdrawal of adult attention functions to reduce the problem behavior in the future. Other brief logical consequences include a short loss of privilege. For example if two children fight over a toy or what to watch on TV, and are unable to problem-solve, a parent might put the toy away temporarily or turn off the TV for a half hour. The key here is to follow through, calmly and consistently. Of course, these are also opportune times to teach children strategies for working out their disagreements.

Conclusion

When fathers understand that disciplining their child is an opportunity to teach by words and actions, they will have an important role in helping their children learn appropriate behavior and self-control. Engaging in fun play, conversation, and the use of fair consequences are times when discipline can be used in positive, nurturing ways.

Valuing Discipline

The following points are taken from the 21st Century Exploring Parenting Program, a Head Start publication. In Session 7 of the program, values are defined as standards of right and wrong that guide behavior. Though most parents do not realize it, their values determine how and why they discipline their children. It is therefore important for parents to evaluate their own values and to understand that every time they discipline their children, they are teaching about values.

Discipline is better understood as guidance and teaching, not controlling and punishing. Over time, children will learn how to control themselves, but until they can, adults need to help them by setting appropriate limits and modeling correct behavior. Discipline is an all day - every day teaching and learning process. These points will help parents as they continue to guide their young children.

• Values are principles and standards that guide our behavior.
• The values that individual family members hold dear vary considerably.
• Parents want their children to accept their values.
• The words "discipline" and "disciple" come from the Latin word "discipulus" which means pupil or student - one who learns.
• Babies need to be loved, nurtured, and accepted as they are. Nothing they do can be called misbehavior.
• Toddlers need adults to make rules that keep them and others safe and protect the family's belongings. They need help in keeping these rules and controlling their behavior.
• Preschoolers still need help in regulating their behavior. They are ready for more explanations about why they must do some things and cannot do others.
• The more time you spend in positive interaction with your children, the more likely it is that they will accept your values and want to please you.
• The combination of positive time together and discipline usually works better than discipline alone.

References

1. Campbell, S.B. 2002. Behavior Problems in Preschool Children: Clinical and Developmental Issues. Second Edition. New York: Guilford Press.DeKlyen, M., Speltz, M.L., Greenberg, M.T. 1998. Fathering and early onset conduct problems: Positive and negative parenting, father-son attachment, and marital conflict. Clinical Child and Family Psychology Review, 1, 3-22.
2. Lamb, M.E. 1987. The father's role: Cross-cultural perspectives. Hillsdale, N.J.: Erlbaum.
3. Lamb, M.E. 1998. Nonparental child care: Context, quality, correlates, and consequences. In W. Damon (Series Ed.) & I. Sigel & A.K. Renninger (Vol. Eds) Handbook of Child Psychology: Volume 4. Child psychology in practice. San Francisco, CA: John Wiley.
4. Lytton, H. 1980. Parent-Child interaction: The socialization process observed in twins and singleton families. New York: Plenum Press.
5. Mash E.J. & Johnston, C. 1983. Sibling interactions of hyperactive and normal children and their relationship to reports of maternal stress and self-esteem. Journal of Clinical Child Psychology. 12, 91-99.
6. Parke, R.D. 1996. Fatherhood. Cambridge: Harvard University Press.
7. Parke, R.D. & Sawin, D.B. 1976. The father's role in infancy: A Reevaluation. The Family Coordinator. 25, 365-371.
8. Pickett, J. et al (Eds). 2000. American Heritage Dictionary. Boston: Houghton Mifflin.
9. W. Douglas Tynan is a clinical psychologist and Director of the Disruptive Behavior Clinic at A. I. duPont Hospital for Children, Wilmington, DE

Head Start Bulletin
Issue No. 77
by W. Douglas Tynan
Last Modified: 06/17/04

Reviewed by athealth on February 4, 2014.

What is a psychodynamic process group and how does it typically work?

A process group typically consists of eight individuals who agree to meet regularly for a specific period of time, depending on the kind of group being hosted. Rules and expectations are agreed upon prior to the beginning of the group, and maybe discussed by members during the group if and when the need arises. A common purpose among those individuals who join a process group is in their wanting to find out more about who they are and, what it is perhaps that they would like to see change with-in their personal lives and in their relationships with others. In essence, a process group is expected to increase emotional awareness and relational understanding between self and others. The work of putting emotional experiences into words can give an individual the cognitive and emotional tools that lend to self-learning, insight and the potential to function with an increased sense of freedom, and with increased sophistication.

The premise of a process group draws from a psychodynamic perspective and is based upon developmental theory. The group is not apt to be influenced to change from 'outside' social pressures and cultural values making it a very specialized and unique psychotherapeutic method of healing. The group as a whole shapes its own unique culture, common values and norms thus, creating a meaningful context upon which it can evolve and grow at its own pace.

The life of a process group from the beginning to the end parallels different developmental stages of growth and maturity. As a group moves forward through its natural stages, the members and the "group-as-a-whole" are assisted with guided feedback and process comments from the leader and or co-leaders. As a result, the group inherently knits together with an abundance of experiences forming and emulating a social microcosm that bears its own unique culture and identity.

A most remarkable and natural phenomenon in the earlier stages of a process group is the way in which individuals, and sub-groups alike repeat the many characteristic ways once developed to survive the stressors and strains in the very first group...the family. Members may remind each other of significant others in their past or present circumstances bringing feelings, thoughts, ideas and fantasies to the fore.

One of the most important keys to a successful process group is when all group members feel sufficiently relaxed and safe to talk as openly as they possibly can about any aspects of the group experience in which they choose to respond. By engaging with one another on different emotional levels, individuals will hopefully gain wider perspectives about the various ways they relate to their inner world and understand how this becomes reflected in their relationships with others.

As awareness increases individuals may begin to recognize newly found aspects of themselves. Individuals and 'the-group-as-a-whole' may actively and unconsciously attempt not to become aware of various emotional aspects of themselves, to avoid uncomfortable and perhaps painful feelings. This is a common phenomenon of human behavior. It is within the supportive and relaxed atmosphere of the group experience that such feelings can be recognized, acknowledged and replaced with conscious, uncontaminated choices in social behaviors and verbal attitudes. The courage to allow these kinds of meaningful connections to take place can help to resolve emotional conflicts and difficulties with feelings of mastery and empowerment.

Once the group members feel more trusting with the leader and other group members, channels of communication are opened, allowing for a genuine and profound sharing of emotional experiences to take place. Thus, feelings of trust and support as well as other identifying therapeutic factors assist in creating room for innovative and creative risk taking with in the group. For each individual the rewards of creating such a place that is their own can be a place that is very real and fully connected. It is a place to be fully who they are without the need to 'fit-in' to a pre-determined pattern.

In summary, being in an experiential process group all members has the opportunity for considerable personal gains, 'corrective emotional experiences' and 'intrapsychic' change that can last a lifetime. Just as individuals bring old learned behaviors and attitudes into the group they may take new ways of inter-relating outside the group. This may enable individuals to cultivate healthier interdependency with others, as well as increased expressions of mature and authentic intimacy.

References:  The Practice of Group Therapy. S.R. Slavson. International Universities Press, 1947 and Analytic Group Psychotherapy with Children, Adolescents and Adults. S.R. Slavson. Columbia University Press, 1964.

Author: Deborah Reeves, MGPGP, LPC, CGP Deborah Reeves is a licensed professional counselor and a certified specialist in group psychotherapy. She has a private clinical and consulting psychotherapy practice in Philadelphia, PA, and is a spokesperson/group leader for ANAD (National Association of Anorexia/Nervosa and Associated Disorders) for the Philadelphia Region. For additional information, visit her Web site at http://www.healing-minds.com

Reviewed by athealth on February 5, 2014.

This report updates and expands the Guidelines for Alzheimer's Disease Management (California Workgroup on Guidelines for Alzheimer's Disease Management, 2002), which itself was a revision of the California Workgroup's original Guideline published in 1998. All of these documents were based upon work begun by the Ad Hoc Standards of Care Committee of the Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs) of California (Hewett, Bass, Hart, Butrum, 1995) and were supported in part by the State of California, Department of Health Services, and the Alzheimer's Association, California Southland Chapter.

PURPOSE AND SCOPE

More than 5 million Americans now have Alzheimer's Disease (Alzheimer's Association, 2008), an increase of 25% since the previous version of this Guideline was published. Alzheimer's Disease destroys brain cells, causing problems with memory, thinking, and behavior severe enough to affect work, family and social relationships, and, eventually, the most basic activities of daily living. Alzheimer's Disease gets worse over time, it is incurable, and it is fatal. Today it is the seventh leading cause of death in the United States, and the fifth leading cause for individuals 65 and older (Alzheimer's Association).

Since the 2002 revision was completed, there has been an explosion of research in the field, generating new insights into the progression, treatment, and management of Alzheimer's Disease. The revised Guideline and this report are based in large part on a review of journal articles and meta-analyses published after 2001, incorporating the results of this tremendous body of new work.

Most older adults - including those with Alzheimer's Disease - receive their medical care from Primary Care Practitioners (PCPs) (Callahan et al., 2006), who may lack the information and other resources they need to treat this growing and demanding population (Reuben, Roth, Kamberg, Wenger, 2003). Nevertheless, PCPs should be able to provide or recommend a wide variety of services beyond medical management of Alzheimer's Disease and comorbid conditions, including recommendations regarding psychosocial issues, assistance to families and caregivers, and referral to legal and financial resources in the community. Many specialized services are available to help patients and families manage these aspects of AD, such as adult day services, respite care, and skilled nursing care, as well as helplines and outreach services operated by the Alzheimer's Association, Area Agencies on Aging, Councils on Aging, and Caregiver Resource Centers. This Guideline is intended to provide assistance to PCPs in offering comprehensive care to patients with Alzheimer's Disease and those who care for them over the course of their illness.

Because the Guideline is intended for use by PCPs who will encounter Alzheimer's Disease in the course of their work, we use the word "patients" throughout this report. However, it is important to recognize that the needs of people with Alzheimer's Disease and their families extend far beyond the realm of medical treatment, and that PCPs will be called upon to provide a wide spectrum of information and resources to assist them in dealing with this challenging, sometimes overwhelming condition.

NEW INFORMATION

The 2002 Guideline was written prior to the development and testing of some new pharmacological agents, as well as numerous non-pharmacological interventions designed to improve disease management and quality of life for both Alzheimer's Disease patients and their caregivers. Although some of these treatment methods were already in use, few were supported by evidence of efficacy from well-designed clinical trials. In many cases, this evidence now exists, and it is discussed in the current revision.

A notable advance in pharmacological treatment of Alzheimer's Disease was the introduction of memantine (Namenda) in October 2003, a year after release of the previous version of this Guideline. The first drug approved by the U.S. Food and Drug Administration (FDA) for treatment of moderate to severe Alzheimer's Disease, memantine has become an important component of treatment for many patients. The Treatment section includes two tables devoted to its use.

In the ensuing 6 years, additional emphasis on other topics relevant to the treatment of Alzheimer's Disease, along with the needs of patients and their families, has become apparent. These topics include, among others:

• the importance of cultural and linguistic factors in Alzheimer's Disease treatment;
• the conduct of legal capacity evaluations; and
• the special needs of early-stage and late-stage patients and their families

The revised report includes much new material regarding these critically important subjects, as well as updated references for many points discussed in previous versions.

NEW FORMAT

This version of the report also has been reformatted for convenience and ease of use, with appendices containing copies of many of the assessment instruments and forms cited in the text. Websites containing valuable resources for both PCPs and patients are included, and the online version of the report contains links to many of these resources.

As with the previous versions, the Guideline's recommendations themselves were designed to fit on one page for handy reference and organized by major care issues (assessment, treatment, patient and family education and support, and legal considerations). The revised and expanded report has been organized to conform to this layout. Each section deals with one of the four care issues and provides an overview of the issue, followed by the care recommendations and a review of the literature supporting them. The language used throughout the report reflects the strength of the supporting evidence, either "strong" (e.g., randomized clinical trial) or "moderate." In some instances, recommendations that are not evidence-based are nevertheless supported by expert opinion and Workgroup consensus, and are labeled as such.

View the full - Guideline for Alzheimer's Disease Management - Final Report 2008

See the updated NIH - Alzheimer's Diagnostic Guideline Validation

Source:

California Workgroup on Guidelines for Alzheimer's Disease Management
California Version © April 2008
Used with permission from the Alzheimer's Association of Los Angeles

---

Reviewed by athealth on February 5, 2014.

Most parents want their young children to have a healthy sense of self-esteem. That desire can also be seen in education--schools around the country include self-esteem among their goals. Many observers believe that low self-esteem lies at the bottom of many of society's problems.

Even though self-esteem has been studied for more than 100 years, specialists and educators continue to debate its precise nature and development. Nevertheless, they generally agree that parents and other adults who are important to children play a major role in laying a solid foundation for a child's development.

What Is Self-Esteem?

When parents and teachers of young children talk about the need for good self-esteem, they usually mean that children should have "good feelings" about themselves. With young children, self-esteem refers to the extent to which they expect to be accepted and valued by the adults and peers who are important to them.

Children with a healthy sense of self-esteem feel that the important adults in their lives accept them, care about them, and would go out of their way to ensure that they are safe and well. They feel that those adults would be upset if anything happened to them and would miss them if they were separated. Children with low self-esteem, on the other hand, feel that the important adults and peers in their lives do not accept them, do not care about them very much, and would not go out of their way to ensure their safety and well-being.

Sidebar: Children with ADHD and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development.

During their early years, young children's self-esteem is based largely on their perceptions of how the important adults in their lives judge them. The extent to which children believe they have the characteristics valued by the important adults and peers in their lives figures greatly in the development of self-esteem. For example, in families and communities that value athletic ability highly, children who excel in athletics are likely to have a high level of self-esteem, whereas children who are less athletic or who are criticized as being physically inept or clumsy are likely to suffer from low self-esteem.

Families, communities, and ethnic and cultural groups vary in the criteria on which self-esteem is based. For example, some groups may emphasize physical appearance, and some may evaluate boys and girls differently. Stereotyping, prejudice, and discrimination are also factors that may contribute to low self-esteem among children.

How Can We Help Children Develop a Healthy Sense of Self-Esteem?

The foundations of self-esteem are laid early in life when infants develop attachments with the adults who are responsible for them. When adults readily respond to their cries and smiles, babies learn to feel loved and valued. Children come to feel loved and accepted by being loved and accepted by people they look up to. As young children learn to trust their parents and others who care for them to satisfy their basic needs, they gradually feel wanted, valued, and loved.

Self-esteem is also related to children's feelings of belonging to a group and being able to adequately function in their group. When toddlers become preschoolers, for example, they are expected to control their impulses and adopt the rules of the family and community in which they are growing. Successfully adjusting to these groups helps to strengthen feelings of belonging to them.

One point to make is that young children are unlikely to have their self-esteem strengthened from excessive praise or flattery. On the contrary, it may raise some doubts in children; many children can see through flattery and may even dismiss an adult who heaps on praise as a poor source of support--one who is not very believable.

The following points may be helpful in strengthening and supporting a healthy sense of self-esteem in your child:

• As they grow, children become increasingly sensitive to the evaluations of their peers. You and your child's teachers can help your child learn to build healthy relationships with his or her peers.
• When children develop stronger ties with their peers in school or around the neighborhood, they may begin to evaluate themselves differently from the way they were taught at home. You can help your child by being clear about your own values and keeping the lines of communication open about experiences outside the home.
• Children do not acquire self-esteem at once nor do they always feel good about themselves in every situation. A child may feel self-confident and accepted at home but not around the neighborhood or in a preschool class. Furthermore, as children interact with their peers or learn to function in school or some other place, they may feel accepted and liked one moment and feel different the next. You can help in these instances by reassuring your child that you support and accept him or her even while others do not.
• A child's sense of self-worth is more likely to deepen when adults respond to the child's interests and efforts with appreciation rather than just praise. For example, if your child shows interest in something you are doing, you might include the child in the activity. Or if the child shows interest in an animal in the garden, you might help the child find more information about it. In this way, you respond positively to your child's interest by treating it seriously. Flattery and praise, on the contrary, distract children from the topics they are interested in. Children may develop a habit of showing interest in a topic just to receive flattery.
• Young children are more likely to benefit from tasks and activities that offer a real challenge than from those that are merely frivolous or fun. For example, you can involve your child in chores around the house, such as preparing meals or caring for pets, that stretch his or her abilities and give your child a sense of accomplishment.
• Self-esteem is most likely to be fostered when children are esteemed by the adults who are important to them. To esteem children means to treat them respectfully, ask their views and opinions, take their views and opinions seriously, and give them meaningful and realistic feedback.
• You can help your child develop and maintain healthy self-esteem by helping him or her cope with defeats, rather than emphasizing constant successes and triumphs. During times of disappointment or crisis, your child's weakened self-esteem can be strengthened when you let the child know that your love and support remain unchanged. When the crisis has passed, you can help your child reflect on what went wrong. The next time a crisis occurs, your child can use the knowledge gained from overcoming past difficulties to help cope with a new crisis. A child's sense of self-worth and self-confidence is not likely to deepen when adults deny that life has its ups and downs.

Conclusion

Parents can play an important role in strengthening children's self-esteem by treating them respectfully, taking their views and opinions seriously, and expressing appreciation to them. Above all, parents must keep in mind that self-esteem is an important part of every child's development.

Sources

1. Amundson, K. 1991. 101 Ways Parents Can Help Students Achieve. Arlington, VA: American Association of School Administrators.
2. Cutright, M. C. February 1992. "Self-Esteem: The Key to a Child's Success and Happiness." PTA Today 17 (4): 5-6.
3. Dusa, G. S. February 1992. "15 Ways Parents Can Boost Self-Esteem." Learning 20 (6): 26-27.
4. Isenberg, J., and N.L. Quisenberry. February 1988. "Play: A Necessity for All Children." A position paper of the Association for Childhood Education International (ACEI). Childhood Education 64 (3): 138-145. EJ 367 943.
5. Katz, L.G. 1993. Distinctions Between Self-Esteem and Narcissism: Implications for Practice. Urbana, IL: ERIC Clearinghouse on Elementary and Early Childhood Education. ED 363 452.
6. Katz, L.G., and S.C. Chard. 1989. Engaging Children's Minds: The Project Approach. Norwood, NJ: Ablex. ED 326 302.
7. Kramer, P. April 1992. "Fostering Self-Esteem Can Keep Kids Safe and Sound." PTA Today 17 (6): 10-11.
8. Markus, H.R., and S. Kitayama. 1991. "Culture and the Self: Implications for Cognition, Emotions, and Motivation." Psychological Review 98 (2): 224-253.
9. McDaniel, S. April 1986. "Political Priority #1: Teaching Kids To Like Themselves." New Options 27: 1.
10. National Association of Elementary School Principals. 1990. Early Childhood Education and the Elementary School Principal: Standards for Quality Programs for Young Children. Alexandria, VA: NAESP.
11. National Association of Elementary School Principals. 1991. The Little Things Make a Big Difference: How To Help Your Children Succeed in School. Alexandria, VA: NAESP.
12. Popkin, Michael, H. 1993. Active Parenting Today: For Parents of 2 to 12 Year Olds. Parent's Guide. Marietta, GA: Active Parenting Publishers.

Source: ERIC Clearinghouse on Elementary and Early Childhood Education
Author: Lilian Katz, 1995

Reviewed by athealth on February 5, 2014.

What are learning disorders?

A student may have a learning disorder if his/her achievement in reading, writing, or mathematics falls below what is expected for the child's age, grade level, and intelligence. To be called a learning disorder, the problems must have a negative impact on the person's academic success or another important area of life requiring math, reading, or writing skills.

What are the different types of learning disorders?

There are three major types of learning disorders:

• Reading disorder
• Mathematics disorder
• Disorder of written expression

What signs are associated with learning disorders?
In addition to the problems associated with the specific type of learning disorder, many students also suffer from:

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

Learning disorders may also be associated with:

• Conduct disorder
• ADD and ADHD
• Depression

Do learning disorders affect males, females, or both?

Learning disorders can affect both males and females. However, in the United States more boys than girls are diagnosed with learning disorders.

At what age do learning disorders appear?

Although learning disorders are most likely present when a child is quite young, the specific type of learning disorder is usually diagnosed in early elementary school when reading, math, and writing begin to be used in the classroom.

How prevalent are learning disorders in our society?

About five percent (5%) of students in the United States have learning disorders.

How are learning disorders diagnosed?

Because standardized, group testing is not accurate enough for this purpose, it is very important that special, psychoeducational tests be individually administered to the child to determine if he/she has a learning disorder. In administering the test, the examiner should give special attention to the child's ethnic and cultural background.

How are learning disorders treated?

Learning disorders are treated with specialized educational methods. In addition to special classroom instruction at school, students with learning disorders frequently benefit from individualized tutoring which focuses on their specific learning problem.

What can people do if they need help?

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

Source: John L. Miller, MD

Reviewed by athealth on February 5, 2014.

What is a mathematics disorder?

Students with a mathematics disorder have problems with their math skills. Their math skills are significantly below normal considering the student's age, intelligence, and education. The poor math skills cause problems with the student's academic success and other important areas in the student's life.

What signs indicate a mathematics disorder?

Students with mathematics disorder have problems which can include the following:

• Writing or printing numbers
• Counting
• Adding and subtracting
• Working with mathematical signs such as +, -, x, and /
• Learning names that include numbers

Students who suffer from mathematics disorders frequently have:

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

Mathematics disorders may also be associated with:

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

Are there genetic factors associated with a mathematics disorder?

It is possible that some people have problems in math because of their genetic makeup. In contrast to some families whose members have great difficulty solving math problems, there are other families who tend to have members that consistently have a very high-level of math functioning.

At what age does mathematics disorder appear?

Mathematics disorder is usually brought to the attention of the child?s parents in second or third grade when math instruction becomes a very important part of the classroom teaching.

How often is mathematics disorder seen in our society?

Although it is difficult to determine exactly, about one percent (1%) of children in the United States suffer from a mathematics disorder.

How is mathematics disorder diagnosed?

Mathematics disorder may be discovered when a student shows poor functioning in several math skills. For instance, if a student has difficulty understanding and working with various math terms and concepts or identifying arithmetic symbols and signs, the student may have mathematics disorder. Also, mathematics disorder may be indicated when the child is unable to attend to details such as carrying numbers or has problems counting and memorizing the multiplication tables.

Although standardized, group testing is important, it alone should not be relied on in making this diagnosis. It is very important that special, psychoeducational tests be individually administered to the child to determine if this learning disorder is present. In administering the test the examiner should give special attention to the child?s ethnic and cultural background.

How is a mathematics disorder treated?

Treatment for mathematics disorder includes individual tutoring, placement in special math classrooms with expert math teachers, and other educational aids that focus on math skills.

What happens to someone with a mathematics disorder?

The course of mathematics disorder is varied. Some students go on to do well in math. Others, even with early intervention and remedial attention, continue to struggle with math in their adult years.

What can people do if they need help?

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

Source: John L. Miller, MD

Reviewed by athealth on February 5, 2014.