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What is a disorder of written expression?

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

What signs are associated with a disorder of written expression?

Signs associated with a disorder of written expression include:

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

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

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

Disorder of written expression may also be associated with:

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

Does this disorder affect both males and females?

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

At what age does a disorder of written expression appear?

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

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

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

How is written expression disorder diagnosed?

The students written work contains errors including:

• spelling
• grammatics
• punctuation
• sentence and paragraph organization

They also have very poor handwriting including:

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

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

How is a disorder of written expression treated?

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

What happens to someone with a disorder of written expression?

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

What can people do if they need help?

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

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

Mental Disorders in America

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

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

Mood Disorders

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

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

Major Depressive Disorder

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

Dysthymic Disorder

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

Bipolar Disorder

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

Suicide

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

Schizophrenia

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

Anxiety Disorders

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

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

Panic Disorder

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

Obsessive-Compulsive Disorder (OCD)

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

Post-Traumatic Stress Disorder (PTSD)

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

Generalized Anxiety Disorder (GAD)

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

Social Phobia

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

Agoraphobia

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

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

Specific Phobia

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

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

Eating Disorders

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

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

Attention Deficit Hyperactivity Disorder (ADHD)

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

Autism

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

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

Personality Disorders

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

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
3. The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. Geneva, Switzerland: WHO, 2008. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_AnnexA.pdf.
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

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Reviewed by athealth on February 8, 2014.

by Alan Siegel, PhD

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

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

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

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

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

Sophia's Spider Dream

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

The Attack of the Dream Spider

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

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

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

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

Children's Nightmares

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

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

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

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

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

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

Poison Gas

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

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

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

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

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

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

Recurring Nightmares

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

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

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

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

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

Stages of Resolution in Recurring Dreams

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

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

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

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

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

Screaming at the Ghost in the Basement

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

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

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

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

Dad Helps Me Float to Safety

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

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

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

The Four R's That Spell Nightmare Relief

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

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

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

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

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

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

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

The Killing Fire

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

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

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

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

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

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

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

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

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

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

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

When To Seek Help for Nightmares

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

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

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

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

Notes

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

Reprinted with permission from Alan Siegel, PhD

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

Reviewed by athealth on February 6, 2014.

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

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

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

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

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

What is the difference between being overweight and being obese?

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

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

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

See the following table for an example.

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

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

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

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

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

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

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

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

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

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

What can be done about this major public health problem?

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

What are the costs associated with overweight and obesity?

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

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

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

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

What are some suggestions for losing weight?

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

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

How can physical activity help prevent overweight and obesity?

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

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

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

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

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

Reviewed by athealth on February 6, 2014.

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

Parenting Style Defined

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

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

Four Parenting Styles

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

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

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

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

Consequences for Children

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

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

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

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

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

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

Sidebar:

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

Influence of Sex, Ethnicity, or Family Type

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

Conclusion

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

For More Information

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

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

Reviewed by athealth on February 6, 2014.

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

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

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

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

How Children Develop

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

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

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

Typical Adolescent Behavior

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

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

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

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

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

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

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

Sidebar:

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

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

Adoption and Adolescence

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

Identity Formation

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

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

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

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

Fear of Abandonment

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

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

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

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

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

Issues of Control

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

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

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

The Feeling of Not Belonging

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

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

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

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

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

The Need to Connect With The Past

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

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

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

When Teens Were Adopted at an Older Age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

Source:

National Adoption Information Clearinghouse

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

Reviewed by athealth on February 6, 2014.

What is a reading disorder?

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

What signs are associated with a reading disorder?

Signs associated with reading disorder include:

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

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

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

Reading disorders may also be associated with:

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

Are there genetic factors associated with a reading disorder?

Reading disorders tend to show up more in certain families.

At what age does a reading disorder appear?

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

How often is a reading disorder seen in our society?

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

How is a reading disorder diagnosed?

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

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

How is a reading disorder treated?

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

What happens to someone with a reading disorder?

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

What can people do if they need help?

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

Developed by John L. Miller, MD

Reviewed by athealth on February 7, 2014.

Why Step Relationships Aren't Easy

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

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

The Entry Adjustment

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

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

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

Adjustment to Parental Remarriage

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

Being Taken Through One's Parents' Changes

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

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

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

Attachment Expectations

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

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

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

Realistic Expectations for the Step Relationship

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

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

Dealing With Step Family Differences

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

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

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

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

The Discussion Contract

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

Role Pressures

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

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

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

Time for the Marriage

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

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

About the Author

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

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

Terms You Need to Know

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

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

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

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

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

Purpose of this Booklet

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

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

What Is Alzheimer's Disease?

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

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

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

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

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

Who Is Affected?

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

Family History of Dementia

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

Down Syndrome

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

What Are the Signs of Alzheimer's Disease?

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

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

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

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

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

Possible Signs of Alzheimer's Disease

Do you have problems with any of these activities?

• Learning and remembering new information.

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

• Handling complex tasks.

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

• Reasoning ability.

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

• Spatial ability and orientation.

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

• Language.

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

• Behavior.

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

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

Consulting the Doctor

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

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

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

Medical and Family History

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

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

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

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

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

Physical Examination

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

Functional Status Assessment

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

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

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

Mental Status Assessment

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

Alzheimer's disease affects two major types of abilities:

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

Treatable Causes of Dementia

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

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

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

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

Special Tests

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

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

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

Getting the Right Care

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

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

Whatever the diagnosis, followup is important.

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

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

Coordinating Care

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

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

Telling Family and Friends

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

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

Where To Get Help?

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

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

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

Other Booklets Are Available

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

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

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

Source: Agency for Healthcare Research and Quality

AHCPR Publication No. 96-0704

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

How Are They Related?

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

How are eating disorders and obesity related?

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

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

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

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

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

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

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

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

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

The environment may contribute to both eating disorders and obesity.

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

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

Health Risks

Eating disorders may lead to

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

Obesity increases the risk for

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

Definitions

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

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

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

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

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

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

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

End Notes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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