Taking Care of Your Mental Health

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.

DO I HAVE A PROBLEM WITH ALCOHOL?

Many women drink alcohol to cope with stress. But some women drink too much. Alcohol abuse and addiction cause stress in a job and family. Answer these questions to help find out if you might have a problem:

  • Have you ever felt you should cut down on your drinking?
  • Have people criticized 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? Talk with your doctor about your drinking if you answered "yes" to one or more questions. Even if you answered "no" to all the questions, talk to your doctor if drinking is causing you problems with your job, relationships, health, work, or the law. 
  • 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 Death Of A Child

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

The Magic of Dialogue

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

Treating Adolescent Survivors of Sexual Abuse

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

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

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

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

Denial is a costly tactic:

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

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

Talking About the Unthinkable

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

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

Child Sexual Abuse: The Impact on Adolescent Development

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

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

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

The Abused Adolescent

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Identity Formation in Adolescence

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

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

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

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

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

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

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

Treating the Sexually Abused Adolescent

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

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

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

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

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

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

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

    General Principles for Working With Youth Who Have Been Sexually Abused

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

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

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

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

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

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

    Understanding Adult Obesity

    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.

    Image 1

    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.

    Use and Misuse of Alcohol Among Older Women

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

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

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

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

    Older Women Have Increased Risks for Alcohol Problems

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

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

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

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

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

    Prevalence of the Problem

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

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

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

    Risk and Benefits Associated with Alcohol Use by Older Women

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

    Risks

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

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

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

    Benefits

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

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

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

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

    Drinking Guidelines and Rationale

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

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

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

    Definitions

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

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

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

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

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

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

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

    Screening and Detection of Alcohol Problems in Older Women

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

    Signs and Symptoms of Alcohol Problems in Older Women

    • Anxiety
    • Increased tolerance to alcohol or medications
    • Depression, mood swings
    • Memory loss
    • Disorientation
    • New difficulties in decisionmaking
    • Poor hygiene
    • Falls, bruises, burns
    • Family problems
    • Idiopathic seizures (i.e., seizures with an unknown origin or cause)
    • Financial problems
    • Sleep problems
    • Headaches
    • Social isolation
    • Incontinence
    • Poor nutrition

    SOURCE: Adapted from Barry et al. 2001.

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

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

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

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

    Prevention, Brief Intervention, and Formal Treatment with Older Women

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

    Brief Alcohol Intervention Goals

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

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

    Effectiveness of Brief Alcohol Interventions with Older At-Risk Drinkers

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

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

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

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

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

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

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

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

    Formal, Specialized Treatment Approaches for Older Women

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

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

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

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

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

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

    Summary

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

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

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

    References

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

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


    Reviewed by athealth on February 8, 2014.

    Written Expression Disorder

    What is a disorder of written expression?

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

    What signs are associated with a disorder of written expression?

    Signs associated with a disorder of written expression include:

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

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

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

    Disorder of written expression may also be associated with:

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

    Does this disorder affect both males and females?

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

    At what age does a disorder of written expression appear?

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

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

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

    How is written expression disorder diagnosed?

    The students written work contains errors including:

    • spelling
    • grammatics
    • punctuation
    • sentence and paragraph organization

    They also have very poor handwriting including:

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

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

    How is a disorder of written expression treated?

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

    What happens to someone with a disorder of written expression?

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

    What can people do if they need help?

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

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

    The Numbers Count: Mental Health Disorders in America

    Mental Disorders in America

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

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

    Mood Disorders

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

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

    Major Depressive Disorder

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

    Dysthymic Disorder

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

    Bipolar Disorder

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

    Suicide

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

    Schizophrenia

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

    Anxiety Disorders

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

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

    Panic Disorder

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

    Obsessive-Compulsive Disorder (OCD)

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

    Post-Traumatic Stress Disorder (PTSD)

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

    Generalized Anxiety Disorder (GAD)

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

    Social Phobia

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

    Agoraphobia

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

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

    Specific Phobia

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

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

    Eating Disorders

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

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

    Attention Deficit Hyperactivity Disorder (ADHD)

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

    Autism

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

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

    Personality Disorders

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

    References

    1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
    2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
    3. The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. Geneva, Switzerland: WHO, 2008. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_AnnexA.pdf.
    4. American Psychiatric Association. Diagnostic and Statistical Manual on Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.
    5. Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 2005 Jun;62(6):593-602.
    6. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 2003; Jun 18;289(23):3095-105.
    7. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) : www.cdc.gov/ncipc/wisqars accessed April 2010.
    8. Conwell Y, Brent D. Suicide and aging I: patterns of psychiatric diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.
    9. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports. 2004 Oct 12;53 (5):1-115.
    10. Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.
    11. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993 Feb;50(2):85-94.
    12. Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
    13. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koen KC, Marshall R. The psychological risk of Vietnam for U.S. veterans: A revist with new data and methods. Science. 2006; 313(5789):979-982.
    14. Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007; 61:348-58.
    15. Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry. 1995 Jul;152(7):1073-4.
    16. Centers for Disease Control and Prevention (CDC). Prevalence of Autism Spectrum Disorders?Autism and Developmental Disabilities Monitoring Network, United States, 2006. MMWR Surveillance Summaries 2009;58(SS-10)
    17. Fombonne E. Epidemiology of autism and related conditions. In: Volkmar FR, ed. Autism and pervasive developmental disorders. Cambridge, England: Cambridge University Press, 1998; 32-63.
    18. Lenzenweger, M.F., Lane, M.C., Loranger, A.W., Kessler, R.C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553-564.

    NIH Publication No. 06-4584
    Updated/Reviewed: July 23, 2010


    Reviewed by athealth on February 8, 2014.

    Nightmare Remedies: Helping Your Child Tame the Demons of the Night

    by Alan Siegel, PhD

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

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

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

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

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

    Sophia's Spider Dream

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

    The Attack of the Dream Spider

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

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

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

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

    Children's Nightmares

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

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

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

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

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

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

    Poison Gas

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

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

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

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

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

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

    Recurring Nightmares

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

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

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

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

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

    Stages of Resolution in Recurring Dreams

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

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

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

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

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

    Screaming at the Ghost in the Basement

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

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

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

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

    Dad Helps Me Float to Safety

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

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

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

    The Four R's That Spell Nightmare Relief

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

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

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

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

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

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

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

    The Killing Fire

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

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

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

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

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

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

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

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

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

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

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

    When To Seek Help for Nightmares

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

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

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

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

    Notes

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

    Reprinted with permission from Alan Siegel, PhD

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

    Reviewed by athealth on February 6, 2014.

    Overweight and Obesity: FAQs

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

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

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

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

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

    What is the difference between being overweight and being obese?

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

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

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

    See the following table for an example.

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

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

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

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

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

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

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

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

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

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

    What can be done about this major public health problem?

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

    What are the costs associated with overweight and obesity?

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

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

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

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

    What are some suggestions for losing weight?

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

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

    How can physical activity help prevent overweight and obesity?

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

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

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

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

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

    Reviewed by athealth on February 6, 2014.