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When should you seek counseling?

From childhood through late adulthood, there are certain times when we may need help addressing problems and issues that cause us emotional distress or make us feel overwhelmed. When you are experiencing these types of difficulties, you may benefit from the assistance of an experienced, trained professional. Professional counselors offer the caring, expert assistance that we often need during these stressful times. A counselor can help you identify your problems and assist you in finding the best ways to cope with the situation by changing behaviors that contribute to the problem or by finding constructive ways to deal with a situation that is beyond your personal control. Professional counselors offer help in addressing many situations that cause emotional stress, including, but not limited to:

• anxiety, depression, and other mental and emotional problems and disorders
• family and relationship issues
• substance abuse and other addictions
• sexual abuse and domestic violence
• eating disorders
• career change and job stress
• social and emotional difficulties related to disability and illness
• adopting to life transitions
• the death of a loved one

"Good indicators of when you should seek counseling are when you're having difficulties at work, your ability to concentrate is diminished or when your level of pain becomes uncomfortable," says Dr. Gail Robinson, past president of the American Counseling Association. "However, you don't want to wait until the pain becomes unbearable or you're at the end of your rope."

"If someone is questioning if they should go into counseling that is probably the best indicator that they should," says Dr. William King, a mental health counselor in private practice in Indianapolis, Indiana. "You should trust your instincts."

Joyce Breasure, past president of the American Counseling Association and a professional counselor who has been in private practice for more than 20 years, recommends counseling when you:

• Spend 5 out of 7 days feeling unhappy
• Regularly cannot sleep at night
• Are taking care of a parent or a child and the idea crosses your mind that you may want to hit that person
• Place an elder in a nursing home or in alternative care
• Have lost someone or something (such as a job)
• Have a chronic or acute medical illness
• Can no longer prioritize what is most important in your life
• Feel that you can no longer manage your stress

"If you're not playing some, working some, and learning some, then you're out of balance. There's a potential for some problems," Breasure says.

Robinson points out you don't have to be "sick" to benefit from counseling. "Counseling is more than a treatment of mental illness," she says. "Some difficult issues we face in life are part of normal development. Sometimes it's helpful to see what you're going through is quite normal."

What is professional counseling?

Professional counselors work with individuals, families, groups and organizations. Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health. Through counseling you examine the behaviors, thoughts and feelings that are causing difficulties in your life. You learn effective ways to deal with your problems by building upon personal strengths. A professional counselor will encourage your personal growth and development in ways that foster your interest and welfare.

Who are professional counselors?

Licensed professional counselors provide quality mental health and substance abuse care to millions of Americans. Professional counselors have a master's or doctoral degree in counseling or a related field which included an internship and coursework in human behavior and development, effective counseling strategies, ethical practice, and other core knowledge areas.

Over 80,000 professional counselors are licensed or certified in 44 states and the District of Columbia. State licensure typically requires a master's or doctoral degree, two to three years of supervised clinical experience, and the passage of an examination. In states without licensure or certification laws, professional counselors are certified by the National Board for Certified Counselors (NBCC). Participation in continuing education is often required for the renewal of a license or certification.

Professional counselors adhere to a code of ethics that protects the confidentiality of the counseling relationship; prohibits discrimination and requires understanding of and respect for diverse cultural backgrounds; and mandates that professional counselors put the needs and welfare of clients before all others in their practice.

Will my health insurance cover counseling?

Many insurance and coverage plans cover mental health services by a licensed professional counselor including some Medicaid programs, CHAMPUS, and other government-sponsored health coverage programs. If you do not have health insurance, or if your coverage does not include mental health care or the services of a professional counselor, many professional counselors will work with clients on a sliding-fee scale or will offer a payment plan. Talk to your counselor about your options.

How much does counseling cost?

The cost of counseling can vary greatly depending on your geographic location and whether counseling is being provided by a community mental health center or similar agency or by a counselor in private practice. In general, the average paid fee for individual counseling sessions is about $65. Fees for group counseling are generally lower, about $35 per group session. For clients with health insurance that does not cover mental health care and others who cannot afford the counselor's standard fee, some counselors will lower their fee on a sliding scale basis or will work out a payment plan. Your counselor should explain to you, prior to beginning the counseling relationship, all financial arrangements related to professional services.

How long does counseling take?

Ideally, counseling is terminated when the problem that you pursued counseling for becomes more manageable or is resolved. However, some insurance companies and managed care plans may limit the number of sessions for which they pay. You should check with your health plan to find out more about any limitations in your coverage. During the first few counseling sessions your counselor should also discuss the length of treatment that may be needed to achieve your goals.

Is everything I say confidential?

All members of the American Counseling Association subscribe to the Code of Ethics and Standards of Practice which require counselors to protect the confidentiality of their communications with clients. Most state licensure laws also protect client confidentiality. As a client, you are guaranteed the protection of confidentiality within the boundaries of the client/counselor relationship. Any disclosure will be made with your full written, informed consent and will be limited to a specific period of time. The only limitations to confidentiality occur when a counselor feels that there is clear and imminent danger to you or to others, or when legal requirements demand that confidential information be disclosed such as a court case. Whenever possible, you will be informed before confidential information is revealed.

How do I find a counselor?

There are many different ways to locate a professional counselor. Some common ways include:

• The National Board for Certified Counselors referral service (phone NBCC at 336-547-0607 between 8:30 a.m. and 4:30 p.m. Eastern Standard Time, Monday through Friday to find a certified counselor in your area)
• The yellow pages listed under counselor, marriage and family counselors, therapist or mental health
• Referral from your physician
• Recommendations from trusted friends
• Crisis hotlines
• Community mental health agencies
• Local United Way information & referral service
• Hospitals
• Child protective services
• Referral from clergy
• Employee Assistance Programs (EAPs)

Once you have found a counselor you are interested in seeing, you should ask several important questions, such as:

• Are you a licensed or certified counselor? What is your educational background? How long have you been practicing counseling?
• What are your areas of specialization (such as family therapy, women's issues, substance abuse counseling, etc.)?
• What are your fees? Do you accept my insurance? How is billing handled? Do you offer a sliding fee scale or a payment plan if I do not have insurance for mental health services?
• How can you help me with my problems? What type of treatment do you use? How long do you think counseling will last?

Some of these questions may be addressed during your initial phone conversation with the counselor and others may be more appropriately discussed in your first face-to-face meeting.

After you have had these questions answered by the counselor to your satisfaction, consider how comfortable you feel with the individual, since you will be working closely together during your counseling sessions. It is difficult to open up and share your problems with a stranger and you may feel awkward or anxious during your initial sessions. But it is also important that you have a "chemistry" or rapport with the counselor. Counselors have different styles, personalities, and approaches. Take time to evaluate how you feel interacting with the counselor and whether you believe that the two of you can work effectively together. If you do not feel at ease with a certain counselor, do not get discouraged. Instead, look for a different individual with whom you would feel more comfortable working with.

Together you and your counselor will set goals, work toward achieving them, and assess how well you are actually meeting them. Counseling can help you maximize your potential and make positive changes in your life. Finally, remember that counseling may be hard work at times but change and progress do happen. A professional counselor can provide the help and support to help you master the challenges of life.

Source: American Counseling Association
http://www.counseling.org

Page last modified or reviewed by athealth on January 29, 2014

Complex Trauma in Children and Adolescents

The term complex trauma describes the dual problem of children's exposure to multiple traumatic events and the impact of this exposure on immediate and long-term outcomes. Typically, complex trauma exposure results when a child is abused or neglected, but it can also be caused by other kinds of events such as witnessing domestic violence, ethnic cleansing, or war. Many children involved in the child welfare system have experienced complex trauma.

Often, the consequences of complex trauma exposure are devastating for a child. This is because complex trauma exposure typically interferes with the formation of a secure attachment bond between a child and her caregiver. Normally, the attachment between a child and caregiver is the primary source of safety and stability in a child's life. Lack of a secure attachment can result in a loss of core capacities for self-regulation and interpersonal relatedness. Children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and other difficulties, including psychiatric and addictive disorders, chronic medical illness, and legal, vocational, and family problems. These difficulties may extend from childhood through adolescence and into adulthood.

The diagnosis of posttraumatic stress disorder (PTSD) does not capture the full range of developmental difficulties that traumatized children experience. Children exposed to maltreatment, family violence, or loss of their caregivers often meet diagnostic criteria for depression, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, anxiety disorders, eating disorders, sleep disorders, communication disorders, separation anxiety disorder, and/or reactive attachment disorder. Yet each of these diagnoses captures only a limited aspect of the traumatized child's complex self-regulatory and relational difficulties. A more comprehensive view of the impact of complex trauma can be gained by examining trauma's impact on a child's growth and development.

Impact on Development

A comprehensive review of the literature suggests seven primary domains of impairment observed in children exposed to complex trauma. Each of the seven domains is discussed below.

Attachment

Complex trauma is most likely to develop if an infant or child is exposed to danger that is unpredictable or uncontrollable, because the child's body must devote resources that are normally dedicated to growth and development instead to survival. The greatest source of danger and unpredictability is the absence of a caregiver who reliably and responsively protects and nurtures the child. The early care giving relationship provides the primary context within which children learn about themselves, their emotions, and their relationships with others. A secure attachment supports a child's development in many essential areas, including his capacity for regulating physical and emotional states, his sense of safety (without which he will be reluctant to explore his environment), his early knowledge of how to exert an influence on the world, and his early capacity for communication.

When the child-caregiver relationship is the source of trauma, the attachment relationship is severely compromised. Care giving that is erratic, rejecting, hostile, or abusive leaves a child feeling helpless and abandoned. In order to cope, the child attempts to exert some control, often by disconnecting from social relationships or by acting coercively towards others. Children exposed to unpredictable violence or repeated abandonment often learn to cope with threatening events and emotions by restricting their processing of what is happening around them. As a result, when they confront challenging situations, they cannot formulate a coherent, organized response. These children often have great difficulty regulating their emotions, managing stress, developing concern for others, and using language to solve problems. Over the long term, the child is placed at high risk for ongoing physical and social difficulties due to:

• Increased susceptibility to stress (e.g., difficulty focusing attention and controlling arousal),
• Inability to regulate emotions without outside help or support (e.g., feeling and acting overwhelmed by intense emotions), and
• Inappropriate help-seeking (e.g., excessive help-seeking and dependency or social isolation and disengagement).

Biology

Toddlers or preschool-aged children with complex trauma histories are at risk for failing to develop brain capacities necessary for regulating emotions in response to stress. Trauma interferes with the integration of left and right hemisphere brain functioning, such that a child cannot access rational thought in the face of overwhelming emotion. Abused and neglected children are then prone to react with extreme helplessness, confusion, withdrawal, or rage when stressed.

In middle childhood and adolescence, the most rapidly developing brain areas are those that are crucial for success in forming interpersonal relationships and solving problems. Traumatic stressors or deficits in self-regulatory abilities impede this development, and can lead to difficulties in emotional regulation, behavior, consciousness, cognition, and identity formation.

It is important to note that supportive and sustaining relationships with adults-or, for adolescents, with peers-can protect children and adolescents from many of the consequences of traumatic stress. When interpersonal support is available, and when stressors are predictable, escapable, or controllable, children and adolescents can become highly resilient in the face of stress.

Affect Regulation

Exposure to complex trauma can lead to severe problems with affect regulation. Affect regulation begins with the accurate identification of internal emotional experiences. This requires the ability to differentiate among states of arousal, interpret these states, and apply appropriate labels (e.g. "happy," "frightened"). When children are provided with inconsistent models of affect and behavior (e.g., a smiling expression paired with rejecting behavior) or with inconsistent responses to affective display (e.g., child distress is met inconsistently with anger, rejection, nurturance, or neutrality), no coherent framework is provided through which to interpret experience.

Following the identification of an emotional state, a child must be able to express emotions safely and to adjust or regulate internal experience. Complexly traumatized children show impairment in both of these skills. Because they have difficulty in both self-regulating and self-soothing, these children may display dissociation, chronic numbing of emotional experience, dysphoria and avoidance of emotional situations (including positive experiences), and maladaptive coping strategies (e.g., substance abuse).

The existence of a strong relationship between early childhood trauma and subsequent depression is well-established. Recent twin studies, considered one of the highest forms of clinical scientific evidence because they can control for genetic and family factors, have conclusively documented that early childhood trauma, especially sexual abuse, dramatically increases risk for major depression, as well as many other negative outcomes. Not only does childhood trauma appear to increase the risk for major depression, it also appears to predispose toward earlier onset of depression, as well as longer duration, and poorer response to standard treatments.

Dissociation

Dissociation is one of the key features of complex trauma in children. In essence, dissociation is the failure to take in or integrate information and experiences. Thus, thoughts and emotions are disconnected, physical sensations are outside conscious awareness, and repetitive behavior takes place without conscious choice, planning, or self-awareness. Although dissociation begins as a protective mechanism in the face of overwhelming trauma, it can develop into a problematic disorder. Chronic trauma exposure may lead to an over-reliance on dissociation as a coping mechanism that, in turn, can exacerbate difficulties with behavioral management, affect regulation, and self-concept.

Behavioral Regulation

Complex childhood trauma is associated with both under-controlled and over-controlled behavior patterns. As early as the second year of life, abused children may demonstrate rigidly controlled behavior patterns, including compulsive compliance with adult requests, resistance to changes in routine, inflexible bathroom rituals, and rigid control of food intake. Childhood victimization also has been shown to be associated with the development of aggressive behavior and oppositional defiant disorder.

An alternative way of understanding the behavioral patterns of chronically traumatized children is that they represent children's defensive adaptations to overwhelming stress. Children may reenact behavioral aspects of their trauma (e.g., through aggression, or self-injurious or sexualized behaviors) as automatic behavioral reactions to trauma reminders or as attempts to gain mastery or control over their experiences. In the absence of more advanced coping strategies, traumatized children may use drugs or alcohol in order to avoid experiencing intolerable levels of emotional arousal. Similarly, in the absence of knowledge of how to form healthy interpersonal relationships, sexually abused children may engage in sexual behaviors in order to achieve acceptance and intimacy.

Cognition

Prospective studies have shown that children of abusive and neglectful parents demonstrate impaired cognitive functioning by late infancy when compared with non-abused children. The sensory and emotional deprivation associated with neglect appears to be particularly detrimental to cognitive development; neglected infants and toddlers demonstrate delays in expressive and receptive language development, as well as deficits in overall IQ. By early childhood, maltreated children demonstrate less flexibility and creativity in problem-solving tasks than same-age peers. Children and adolescents with a diagnosis of PTSD secondary to abuse or witnessing violence demonstrate deficits in attention, abstract reasoning, and problem solving.

By early elementary school, maltreated children are more frequently referred for special education services. A history of maltreatment is associated with lower grades and poorer scores on standardized tests and other indices of academic achievement. Maltreated children have three times the dropout rate of the general population. These findings have been demonstrated across a variety of trauma exposures (e.g., physical abuse, sexual abuse, neglect, and exposure to domestic violence) and cannot be accounted for by the effects of other psychosocial stressors such as poverty.

Self-Concept

The early caregiver relationship has a profound effect on a child's development of a coherent sense of self. Responsive, sensitive caretaking and positive early life experiences allow a child to develop a model of self as generally worthy and competent. In contrast, repetitive experiences of harm and/or rejection by significant others and the associated failure to develop age-appropriate competencies are likely to lead to a sense of self as ineffective, helpless, deficient, and unlovable. Children who perceive themselves as powerless or incompetent and who expect others to reject and despise them are more likely to blame themselves for negative experiences and have problems eliciting and responding to social support.

By 18 months, maltreated toddlers already are more likely to respond to self-recognition with neutral or negative affect than non-traumatized children. In preschool, traumatized children are more resistant to talking about internal states, particularly those they perceive as negative. Traumatized children have problems estimating their own competence. Early exaggerations of competence in preschool shift to significantly lowered estimates of self-competence by late elementary school. By adulthood, they tend to suffer from a high degree of self-blame.

Family Context

The family, particularly the child's mother, plays a crucial role in determining how the child adapts to experiencing trauma. In the aftermath of trauma, family support and parents' emotional functioning strongly mitigate the development of PTSD symptoms and enhance a child's capacity to resolve the symptoms.

There are three main elements in caregivers' supportive responses to their children's trauma:

• Believing and validating the child's experience,
• Tolerating the child's affect, and
• Managing the caregiver's own emotional response.

When a caregiver denies the child's experiences, the child is forced to act as if the trauma did not occur. The child also learns she cannot trust the primary caregiver and does not learn to use language to deal with adversity. It is important to note that it is not caregiver distress per se that is necessarily detrimental to the child. Instead, when the caregiver's distress overrides or diverts attention away from the needs of the child, the child may be adversely affected. Children may respond to their caregiver's distress by avoiding or suppressing their own feelings or behaviors, by avoiding the caregiver altogether, or by becoming "parentified" and attempting to reduce the distress of the caregiver.

Caregivers who have had impaired relationships with attachment figures in their own lives are especially vulnerable to problems in raising their own children. Caregivers with histories of childhood complex trauma may avoid experiencing their own emotions, which may make it difficult for them to respond appropriately to their child's emotional state. Parents and guardians may see a child's behavioral responses to trauma as a personal threat or provocation, rather than as a reenactment of what happened to the child or a behavioral representation of what the child cannot express verbally. The victimized child's simultaneous need for and fear of closeness also can trigger a caregiver's own memories of loss, rejection, or abuse, and thus diminish parenting abilities.

Ethnocultural Issues

Children's risk of exposure to complex trauma, as well as child and family responses to exposure, can also be affected by where they live and by their ethnocultural heritage and traditions. For example, war and genocide are prevalent in some parts of the world, and inner cities are frequently plagued with high levels of violence and racial tension. Children, parents, teachers, religious leaders, and the media from different cultural, national, linguistic, spiritual, and ethnic backgrounds define key trauma-related constructs in many different ways and with different expressions. For example, flashbacks may be "visions," hyperarousal may be "un ataque de nervios," and dissociation may be "spirit possession." These factors become important when considering how to treat the child.

Resilience Factors

While exposure to complex trauma has a potentially devastating impact on the developing child, there is also the possibility that a victimized child may function well in certain domains while exhibiting distress in others. Areas of competence also can shift as children are faced with new stressors and developmental challenges.

Several factors have been shown to be linked to children's resilience in the face of stress: positive attachment and connections to emotionally supportive and competent adults within the family or community, development of cognitive and self-regulation abilities, and positive beliefs about oneself and motivation to act effectively in one's environment. Additional individual factors associated with resilience include an easygoing disposition, positive temperament, and sociable demeanor; internal locus of control and external attributions for blame; effective coping strategies; a high degree of mastery and autonomy; special talents; creativity; and spirituality.

The greatest threats to resilience appear to follow the breakdown of protective systems. This results in damage to brain development and associated cognitive and self-regulatory capacities, compromised caregiver-child relationships, and loss of motivation to interact with one's environment.

Assessment and Treatment

Regardless of the type of trauma that leads to a referral for services, the first step in care is a comprehensive assessment. A comprehensive assessment of complex trauma includes information from a number of sources, including the child's or adolescent's own disclosures, collateral reports from caregivers and other providers, the therapist's observations, and standardized assessment measures that have been completed by the child, caregiver, and, if possible, by the child's teacher. Assessments should be culturally sensitive and language-appropriate. Court evaluations, where required, must be conducted in a forensically sound and clinically rigorous manner.

The National Child Traumatic Stress Network is a partnership of organizations and individuals committed to raising the standard of care for traumatized children nationwide. The Complex Trauma Workgroup of the National Child Traumatic Stress Network has identified six core components of complex trauma intervention:

• Safety: Creating a home, school, and community environment in which the child feels safe and cared for
• Self-regulation: Enhancing a child's capacity to modulate arousal and restore equilibrium following disregulation of affect, behavior, physiology, cognition, interpersonal relatedness and self-attribution.
• Self-reflective information processing: Helping the child construct self-narratives, reflect on past and present experience, and develop skills in planning and decision making.
• Traumatic experiences integration: Enabling the child to transform or resolve traumatic reminders and memories using such therapeutic strategies as meaning-making, traumatic memory containment or processing, remembrance and mourning of the traumatic loss, symptom management and development of coping skills, and cultivation of present-oriented thinking and behavior.
• Relational engagement: Teaching the child to form appropriate attachments and to apply this knowledge to current interpersonal relationships, including the therapeutic alliance, with emphasis on development of such critical interpersonal skills as assertiveness, cooperation, perspective-taking, boundaries and limit-setting, reciprocity, social empathy, and the capacity for physical and emotional intimacy.
• Positive affect enhancement: Enhancing a child's sense of self-worth, esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery-seeking, community-building and the capacity to experience pleasure.

In light of the many individual and contextual differences in the lives of children and adolescents affected by complex trauma, good treatment requires the flexible adaptation of treatment strategies in response to such factors as patient age and developmental stage, gender, culture and ethnicity, socioeconomic status, and religious or community affiliation. However, in general, it is recommended that treatment proceed through a series of phases that focus on different goals. This can help avoid overloading children-who may well already have cognitive difficulties-with too much information at one time.

A phase-based approach begins with a focus on providing safety, typically followed by teaching self-regulation. As children's capacity to identify, modulate and express their emotions stabilizes, treatment focus increasingly incorporates self-reflective information processing, relational engagement, and positive affect enhancement. These additional components play a critical role in helping children to develop in positive, healthy ways, and to avoid future trauma and victimization.

While it may be beneficial for some children affected by complex trauma to process their traumatic memories, this typically can only be successfully undertaken after a substantial period of stabilization in which internal and external resources have been established. Notably, several of the leading interventions for child complex trauma do not include revisiting traumatic memories but instead foster integration of traumatic experiences through a focus on recognizing and coping with present triggers within a trauma framework.

Best practice with this population typically involves adoption of a systems approach to intervention, which might involve working with child protective services, the court system, the schools, and social service agencies. Finally, there is a consensus that interventions should build strengths as well as reduce symptoms. In this way, treatment for children and adolescents also serves to protect against poor outcomes in adulthood.

References

This article has been adapted from the following sources:

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M.; Cloitre, M, DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.

Cook, A., Blaustein, M., Spinazzola, J, & van der Kolk, B. (Eds.). Complex trauma in children and adolescents. National Child Traumatic Stress Network. www.nctsnet.org/nccts/nav.do?pid=typ_ct

Authors

Alexandra Cook, Joseph Spinazzola, Julian Ford, Cheryl Lanktree, Margaret Blaustein, Caryll Sprague, Marylene Cloitre, Ruth DeRosa, Rebecca Hubbard, Richard Kagan, Joan Liautaud, Karen Mallah, Erna Olafson, Bessel van der Kolk.

The authors wish to acknowledge the contributions of the Complex Trauma Workgroup of the National Child Traumatic Stress Network.

Source:
Focal Point: A National Bulletin on Family Support and Children's Mental Health
Winter 2007 Focal Point, Vol. 21, No. 1
Used with permission
Research and Training Center
Portland State University
http://www.pdx.edu/

Page last modified or reviewed by February 2, 2014

For many years, depression and other disorders of mood were thought to be afflictions of only adults. Within the past three decades, however, it has become evident that mood disorders are common among children and adolescents. Population studies reveal that between 10% and 15% of the child and adolescent population exhibit some symptoms of depression (U. S. Department of Health and Human Services [USDHHS], 2000).

In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. This digest focuses on these three disorders as they are exhibited in childhood and adolescence - their symptoms, causal factors, and treatment.

Major Depressive Disorder

Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts an average of seven to nine months (Birmaher et al., 1996a, 1996b). Depressed children are sad and lose interest in activities they used to enjoy. They feel unloved, pessimistic, or even hopeless; they think that life is not worth living; and they may think about or threaten suicide. They are often irritable, which may lead to disruptive or aggressive behavior. They may be indecisive, have problems concentrating, and lack energy or motivation. They may neglect appearance and hygiene, and their normal eating and sleeping patterns may be disturbed (USDHHS, 2000).

Dysthymic Disorder

Dysthymic disorder has fewer symptoms, but is more persistent. The child or adolescent is depressed for most of the day on most days, and symptoms may continue for several years, the average dysthymic period being approximately four years. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression. When this combination of major depression and dysthymia occurs, the condition is referred to as double depression (USDHHS, 2000).

Bipolar Disorder

In bipolar disorder, episodes of depression alternate with episodes of mania. The depressive episode usually comes first, with the first manic features becoming evident months or even years later. Adolescents with mania feel energetic and confident; may have difficulty sleeping but do not tire; and talk a great deal, often speaking very loudly or rapidly. They may complain of racing thoughts. They may do schoolwork quickly and creatively, but in a chaotic, disorganized way. In the manic stage, they may have exaggerated or even delusional ideas about their capabilities and importance, become overconfident, and be uninhibited with others. They may engage in reckless behavior (e. g., fast driving or unsafe sex). Sexual preoccupations are increased and may be associated with promiscuous behavior (USDHHS, 2000).

Other Disabilities Associated With Depressive Disorders

Approximately two-thirds of children and adolescents with major depressive disorder also have another mental disorder, such as anxiety disorder, conduct disorder, oppositional defiant disorder, psychoactive substance abuse or dependence, or phobias (Anderson & McGee, 1994). Authorities have also noted that children with medical problems often face extreme and/or chronic stress, which places them at risk for depression. Estimates of depression among youngsters with medical problems range from 7% in general medical patients to 23% in orthopedic patients (Guetzloe, 1991). Depression has also been linked to a variety of other medical conditions, including endocrinopathies and metabolic disorders (e.g., diabetes and hypoglycemia), viral infections (e.g., influenza, viral hepatitis, and viral pneumonia), rheumatoid arthritis, cancer, central nervous system disorders, metal intoxications, and disabling diseases of all kinds. Some of these conditions may be temporary, but some may be diagnosed as primary disabilities in youngsters with health impairments.

The Link Between Depression and Suicide

A number of studies have confirmed that children and adolescents with depression are at high risk for suicidal behavior (see Guetzloe, 1991). Because mood disorders substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for parents, educators, and clinicians who deal with the mental health problems of children and adolescents. Over 90% of children and adolescents who commit suicide have a mental disorder (USDHHS, 2000).

Causal Factors Related to Depression

The precise causes of depression are not known. Research on adults with depression generally points to both biological and psychosocial factors, but there has been considerably less research on children and adolescents (Kendler, 1995).

• Family and genetic factors. Between 20% and 50% of depressed children and adolescents have a family history of depression. It is not clear whether the relationship between parent and childhood depression derives from genetic factors or if depressed parents create an environment in which children are more likely to develop mental disorders (USDHHS, 2000).
• Biological factors. Biochemical and physiological correlates of depression have been studied by medical researchers, with results that generally point to a chemical imbalance in the brain as a causal factor (Birmaher et al., 1996a,1996b). Most of these studies have been conducted with adults, so the findings may not apply to children and adolescents (Guetzloe, 1991).
• Cognitive factors. For several decades there has been considerable interest in the relationship between a pessimistic mindset and a predisposition to depression. Pessimistic individuals generally react more passively, helplessly, and ineffectively to negative events than optimistic individuals. The specific origins of pessimistic mindset have not been established (USDHHS, 2000) but are topics of current research interest (Alloy et al., 2001; Garber & Flynn, 2001).

Diagnosis and Assessment of Depressive Illness in Young People

Recent research has focused on the development and validation of checklists and protocols to be used by mental health professionals along with clinical interviews and medical tests. An accurate diagnosis of depression is a complex task, extremely difficult for even highly skilled physicians and other clinicians. It requires a careful examination of physical, mental, emotional, environmental, and cultural factors related to the child or adolescent, his/her family, and the environment. Teachers, counselors, and other school personnel are not expected to diagnose depression in young people; the major roles of educators are to detect the symptoms of depression and make appropriate referrals.

Treatment of Depressive Disorders

Treatment approaches for children and adolescents include psychosocial interventions (e. g., cognitive behavior therapy) and medication, as well as traditional psychotherapy. Two forms of cognitive therapy (i.e., self-control therapy for prepubertal children and coping skills for adolescents) have been judged as probably effective (Kaslow & Thompson, 1998). A number of medications are commonly prescribed for children and adolescents with depression, but many of these have not yet been subjected to sufficient study. Effective treatment requires intervention by both medical and mental health professionals, with support from all others who come in contact with the young person; and is therefore not within the purview of the school alone.

School and Classroom Intervention

The educator's most important contribution is the provision of a positive and supportive environment, components of which include satisfaction of basic needs, caring relationships with adults, and physical and psychological security. Any inclusion in a student's program that serves to enhance feelings of self-worth, self-control, and optimism has the potential for ameliorating feelings of depression. Aversive techniques (e. g., punishment and "get tough" approaches) should be avoided to the extent possible (Guetzloe, 1989, 1991).

Educators must use instructional strategies that are both positive and effective so that the student will achieve success and enjoy the learning process. Examples include direct instruction with positive reinforcement, thematic instructional units with varied levels of classroom assignments, learning strategies (e. g., mnemonic devices) and utilization of the principles of universal design for leaning, which promote access to the general curriculum for students with learning problems. Some protective factors have been addressed in published curricula (e. g., preventing alienation, enhancing self-esteem, and learning self-control). Other interventions that have implications for school programs (e. g., phototherapy and exercise) have been found to have value in reducing symptoms of depression in adults (Brosse, Sheets, Lett, & Blumenthal, 2002; USDHHS, 2003), but have not yet been subjected to sufficient study with children and adolescents.

Summary

Mood disorders, including major depression, dysthymia, and bipolar disorder, are now recognized as serious problems among children and adolescents. This brief discussion has focused on the symptoms of these disorders, their relationships to other mental and physical problems, their treatment, and appropriate school intervention.

Resources

Alloy, L.B., Abramson, L.Y., Tashman, N., Berrebbi, D.S., Hogan, M.E., Whitehouse, W.G., Crossfield, A.G., & Morocco, A. (2001). Developmental origins of cognitive vulnerability to depression: Parenting, cognitive, and inferential feedback styles of the parents of individuals at high and low cognitive risk for depression. Cognitive Therapy and Research, 25, 397-423.

Anderson, J. C., & & McGee, R. (1994). Comorbidity of depression in children and adolescents. In W. M. Reynolds & H. F. Johnson (Eds.), Handbook of depression in children and adolescents (pp. 581-601). New York: Plenum.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., & Kaufman, J. (1996a). Childhood and adolescent depression: A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1575-1583.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996b). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427-1439.

Brosse, A. L., Sheets, E. S., Lett, H. S., & Blumenthal, J. A. (2002). Exercise and the treatment of clinical depression in adults: Recent findings and future directions. Sports Medicine 32 (12),741-760.

Garber, A., & Flynn, C. A. (2001).Predictors of depressive cognitions in young adolescents. Cognitive Therapy and Research, 25, 353-376.

Guetzloe, E. C. (1991). Depression and suicide: Special education students at risk. Reston, VA: Council for Exceptional Children.

Guetzloe, E. C. (1989). Youth suicide: What the educator should know. Reston, VA: The Council for Exceptional Children.

Kaslow, N. J., & Thompson, M. P. (1998). Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression. Journal of Clinical Child Psychology, 27, 146-155.

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Source: ERIC Digest
ERIC Clearinghouse on Disabilities and Gifted Education
ERIC Identifier: ED482340
Publication Date: 2003-08-00
Author: Eleanor Guetzloe

Reviewed by athealth.com February 3, 2014

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. -- Harlan Gephart, MD

Athealth.com: We are pleased to welcome Harlan Gephart, MD, Past Chair of the American Board of Pediatrics and an ADHD expert, who talks about the diagnosis and treatment of attention deficit / hyperactivity disorder. Dr. Gephart, former director of the Group Health ADHD Clinic, is the ADHD consultant at Pediatric Associates in Bellevue, Washington, and a Clinical Professor of Pediatrics at the University of Washington Medical School in Seattle. He is a member of the editorial boards of Contemporary Pediatrics and Journal Watch - Pediatric and Adolescent Medicine. Dr. Gephart has also served as the pediatric delegate to the American Board of Medical Specialists and as a member of the Future of Pediatric Education II Project (FOPE II), the national joint task force of pediatric societies studying pediatric practice and education into the 21st century.

Athealth.com: How did you become interested in ADHD?

Dr. Gephart: I completed a pediatric residency at the University of Washington and particularly enjoyed the behavioral side of pediatrics. I considered taking a residency in child psychiatry, but the Viet Nam war intervened, and after I completed a tour of duty with the Air Force, I decided to take additional training in behavioral pediatrics. I returned to the University of Washington as chief resident in pediatrics and spent much of that year at what is now called the Center for Human Development and Disability, working with Dr. Michael Rothenberg, a nationally-known pediatrician / child psychiatrist.

Following my fellowship, I joined Group Health as a general pediatrician. My interest in ADHD and behavioral pediatrics was fueled by my work as physician for one of the local school districts and the significant number of ADHD patients that I was seeing in my practice.

Athealth.com: How did the Center for Attention Deficit Disorders at Group Health come into being?

Dr. Gephart: Another physician, Dr. Connie McDonald, who was a fully trained developmental pediatrician, and I established the clinic in 1989.

It was becoming increasingly difficult for primary care physicians to carve out the block of time necessary to do a complete assessment for ADHD, and we were receiving a large number of these kinds of referrals. We needed a place where we could facilitate the assessment and management of children with the disorder. When Dr. McDonald retired in 1990, I became medical director of the center, and for a number of years I practiced half time in the center and half time in general pediatrics. Today, I limit my practice to half time, but devote 100% of my practice time to assessments, medication management, supervision, teaching, and administration at the center.

Athealth.com: How many patients have been assessed at the center?

Dr. Gephart: We have assessed or managed between 5,000 - 6,000 young people.

Athealth.com: How are patients referred to the center?

Dr. Gephart: We receive around 40 - 50 referrals each month. The majority of our referrals come from within the Group Health system, but about 10% - 15% of the kids are private patients referred to our center from outside of Group Health. About two-thirds to three-quarters of our referrals come from family doctors, and the rest generally come from pediatricians or mental health care providers.

Athealth.com: Why aren't these patients assessed for ADHD by their own health care providers?

Dr. Gephart: The family physician may not have time to conduct a comprehensive evaluation, or his/her clinical expertise may lie elsewhere. Some clinicians do not feel comfortable diagnosing ADHD, but they are able to manage the treatment of the child once the diagnosis is made.

The referrals we receive from pediatricians are often the more complex cases not easily managed in a general pediatric practice. Mental health care providers may refer to the center for an assessment and then rely on us for medication management.

Athealth.com: What is the prevalence of ADHD?

Dr. Gephart: Prevalence estimates vary, but among school-aged children the prevalence is estimated to be between 6% - 10%.

Athealth.com: Why is it important to treat ADHD?

Dr. Gephart: Attention deficit/hyperactivity disorder is the most common behavioral disorder of childhood. Children with ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity, and as a result, they frequently experience school problems, have difficulty with peers and family members, and show poor psychosocial development. They are at higher risk for teen pregnancy, substance abuse, and other comorbid conditions, and they are more likely to drop out of school at an early age. Virtually all children with ADHD suffer from low self-esteem.

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. If we let an ADHD child go untreated, we may well be handing that child a life sentence of academic and social failure.

Athealth.com: What is being done to improve the diagnosis and treatment of ADHD?

Dr. Gephart: In recent years a significant effort has been made to develop evidence-based guidelines that standardize the diagnosis and treatment of the disorder. For example, the American Academy of Pediatrics (AAP) recently published guidelines for the diagnosis and treatment of ADHD in children 6 to 12 years of age. The American Academy of Child and Adolescent Psychiatry has published similar guidelines.

The next important step is developing effective programs that teach physicians, nurses, mental health providers, school staff, and other members of the treatment team how to apply the guidelines.

Athealth.com: How do you conduct an ADHD assessment?

Dr. Gephart: ADHD assessments require a considerable amount of time and effort. At the center we plan about four hours for an initial assessment.

The diagnosis of ADHD requires that a child meet the criteria set forth in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). A complete assessment includes the following:

A complete history from the child's parent or caretaker, including information about the child's inattention, hyperactivity, and impulsivity, the age of onset of the symptoms, and the extent of the child's academic and social impairment;

Behavior and academic reports, including report cards and samples of school work, from the child's school. It is also helpful to gather information from other collateral resources such as counselors, day care providers, or coaches if they have significant contact with the child.

Use of ADHD-specific behavior rating scales and questionnaires. Scales are used in an attempt to quantify the level of the child's impairment. All kids have some characteristics of ADHD. However, if a child has ADHD, the symptoms will be clinically significant for longer than 6 months and will manifest themselves in at least two environments, typically at home and at school. The scales also assist us in establishing a baseline so that once the condition is treated, we have something against which we can measure improvement.

The AAP guidelines recommend several parent and teacher rating scales, including:

• CPRS-R:L-ADHD Index (Conners Parent Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CTRS-R:L-ADHD Index (Conners Teacher Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CPRS-R:L-DSM-IV Symptoms (Conners Parent Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale); and
• CTRS-R:L-DSM-IV Symptoms (Conners Teacher Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale).

A complete physical examination, including a neurological examination if indicated, to determine if there is a physical reason for the problem, such as a visual or hearing impairment or a genetic disorder;

An interview with the child separate from the physical examination;

An assessment for co-existing conditions. There are a number of look alike and/or co-occurring disorders associated with ADHD - depression, anxiety, substance abuse, learning disorders, conduct disorder, oppositional defiant disorder (ODD), and Tourette syndrome to name a few.

It is not uncommon for an ADHD child to have a co-existing condition. In patients with ADHD about fifty percent (50%) fulfill the criteria for ODD and about twenty-five percent (25%) fulfill the criteria for conduct disorder.

Learning disorders are two times more common in children with ADHD. If an ADHD child is performing below grade level in school, the clinician should recommend that the school conduct a psychoeducational evaluation.

Athealth.com: What causes ADHD and can it be cured?

Dr. Gephart: We don't have a complete answer for what causes ADHD, but we certainly understand a great deal more than we did. We now know that:

• ADHD doesn't occur because the parent is a bad parent or because the child is a bad kid;
• ADHD runs in families;
• ADHD may, at least in part, be caused by neurotransmitter deficits;
• Although chronic, ADHD is a highly treatable medical condition.

We used to say that ADHD kids would eventually outgrow the disorder. Today, we know that inattention and lack of organization can persist into adulthood - although hyperactivity and impulsivity tend to diminish with age.

School is a burden for kids with ADHD. In adults, it isn't that the disorder goes away, it's that school goes away, and therefore, the focus on the symptoms and the resultant impairment is often reduced.

Athealth.com: What about girls with ADHD?

Dr. Gephart: I would say that ADHD is under-diagnosed in girls. This may be, in part, because girls with ADHD tend to be more inattentive than hyperactive, and therefore, draw less attention to themselves. In recent years we have come to recognize that this disorder has a significant impact on girls, too.

For example, it was previously thought that ADHD was ten times more common in boys than in girls. However, recent studies indicate that the ratio is much lower than that, i.e., ADHD is four times more common in boys than in girls. As patients get older, the ratios are reduced. In adults, the ratio between males and females with ADHD is 1:1.

In our clinic we see two definite referral spikes related to age and gender:

The first referral spike occurs around the first grade where we see a large influx of hyperactive boys, ages 5 - 7.

The second referral spike occurs around the sixth grade, and girls are predominate in this referral group. Often, these are previously well-liked girls who, once they reach middle school, are overwhelmed by classroom changes, increased assignments, and large class sizes. They begin to fall further behind academically, and they start to struggle socially.

The DSM-IV criteria are somewhat limited with regard to diagnosing ADHD in girls. Prior to reaching middle school, the inattentive girl may not exhibit all of the symptoms required by the DSM-IV, and as a result, the diagnosis may be missed.

Athealth.com: Is the evaluation and treatment for boys different than for girls?

Dr. Gephart: The assessment and the treatment are the same. However, if the patient is a hyperactive, impulsive child, that child will require more intervention. And, since boys tend to be more hyperactive than girls, boys will often require more intense intervention than girls.

Athealth.com: Do you treat children differently than you treat teenagers?

Dr. Gephart: No. Teenagers respond to stimulant medication and behavioral treatment approaches in the same ways that younger children do. However, teenagers have more control over how they participate in treatment, and therefore, adolescents present a different set of compliance issues than children do.

Athealth.com: How is ADHD treated?

Dr. Gephart: There are two proven treatments:

Stimulant medication such as Ritalin, Dexedrine, and Adderall, and

Behavioral therapy such as parent training, social skills programs, and the daily report card.

The best treatment involves the use of both approaches.

In parent training classes parents learn how to work with their kids on a daily basis. These programs focus on teaching parents how to deal with the child's social and academic problems - when to use time-outs, how to give clear, concise instructions to the child, how to set up a system of rewards and consequences. It is important to keep in mind that many ADHD kids have ADHD parents. The parents, therefore, may forget to give the child his/her medication or be disorganized in their approach to the child. These programs teach parents how to be more successful in dealing with the child.

Many ADHD children exhibit socially inappropriate behavior and have problems getting along with siblings and peers. Social skills programs, particularly camping programs that provide intense intervention, group work, and a lot of one-on-one assistance, can help these kids learn skills in problem solving, working with others, and anger management. ADHD kids need to experience success, and when a child learns how to interact appropriately with others, this can be an important self-esteem builder.

The daily report card is a tool used by the school to give more immediate feedback to the parent (and the clinician) about the child's progress. The report card focuses both on behavior and academics, and a system of rewards and consequences can be designed to reinforce the performance goals.

Athealth.com: We hear a lot in the media that ADHD is over-diagnosed and that kids are over-medicated. Can you comment on this?

Dr. Gephart: People are certainly more aware of the disorder. Although there may be evidence of over-prescribing in some communities, one recent study concluded that, in fact, ADHD is actually under-diagnosed in the U.S., that only 50% of children with ADHD are actually being treated with stimulant medication (despite its proven effectiveness), and that for a significant number of children who are taking stimulant medication, the treatment is inadequate.

In addition, it is possible that prescribing variations could be attributed to such wide-ranging factors as inconsistent care, affluent neighborhoods where families have more resources to cover the costs of diagnosis and treatment, or a greater number of child psychiatrists and other clinicians in a community who are trained to make the diagnosis.

Athealth.com: What do you do if parents are resistant to giving their child medication?

Dr. Gephart: I think the key is to spend a lot of time conducting a careful assessment before ever talking to parents about medication and other treatment options. Most parents are eager for help, but they want to be certain that their child has been properly evaluated, and they may be resistant to certain treatments if they feel their child has not received a complete evaluation. Also, practitioners need to spend time giving parents information about the pluses and minuses of each intervention and educating families about how to manage the disorder.

In our clinic we schedule a separate appointment to discuss treatment options. For parents who don't want to use medication, we recommend parent groups, skills training, and other educational interventions.

With regard to medication, a more common problem is the ADHD teen that refuses to take his/her medication. In such situations adherence to the treatment plan is disrupted, and we have to develop strategies that encourage the teen to participate in the treatment.

Athealth.com: Is there any concern about the risk of increased substance abuse for kids taking ADHD medication?

Dr. Gephart: ADHD kids are at increased risk for substance abuse, but research indicates that ADHD kids who are on stimulant medication are not more prone to substance abuse. In fact, early treatment reduces the risk of substance abuse.

We do talk to kids about the possibility of adverse drug reactions if they use alcohol or other substances while taking their medications. Unfortunately, this doesn't necessarily mean that they refrain from the use of alcohol or drugs. The more likely result is that they may not take their medication when they are drinking.

Athealth.com: Do you find that kids share their medications with other students?

Dr. Gephart: Generally, this has not been a problem in my practice. Kids know that the medication helps them, and even though they may not like to take it, they recognize that there are benefits when they do take it.

Athealth.com: How important is it to work with the school and others who have significant contact with the child?

Dr. Gephart: It is very important. Treating an ADHD child is a team effort. Parents, teachers, nursing staff, mental health professionals, case managers, and others are essential members of the team and are critical to the success of the treatment. We also need to remember that building a therapeutic alliance with the child is an important component.

In treating ADHD we use a chronic illness treatment model as opposed to an acute illness treatment model. Consequently, treatment is usually a long-term proposition that requires the implementation of a medication schedule as well as education and behavioral interventions at home, in day care, at school, and wherever else the child spends time.

Athealth.com: Earlier you mentioned the importance of obtaining a learning assessment. Can you comment further on that?

Dr. Gephart: It is essential to determine if the child has a comorbid learning disorder. ADHD kids slowly fall behind in school. They may have normal IQs, but they frequently perform below grade level.

These kids daydream and are easily distracted. They find it hard to process language, organize their materials, and pay attention to details - tasks that are required in all educational settings. If a child is not paying attention for one-third of the day, that child is essentially missing every third day of school.

The parent or the clinician can initiate a request for a learning assessment. There are at least two federal statues that apply to children with disabilities:

The Individuals with Disabilities Education Act (IDEA) and

Section 504 of the Rehabilitation Act of 1973.

IDEA governs special education, and Section 504 provides for reasonable accommodations for children with disabilities. It is difficult to get kids into special education, but ADHD kids can receive certain accommodations such as extra time for tests, preferential seating, taking tests in a quiet room, and so on. Parents can be a great deal of help in advocating for the child on these kinds of issues.

Athealth.com: In 1999 you wrote an article entitled, The ADHD History: 42 Questions to Ask Parents (Contemporary Pediatrics 1999;10:127-128, 130-136), in which you described a list of questions that you use when evaluating a child for ADHD. Describe some of those questions.

Dr. Gephart: In my initial interview with the parents I try to ask such questions as: Does your child have a history of accidents or injuries? How does your child react to schedule changes? Does your child sit quietly when watching TV? Does anyone in the family have ADHD or learning problems? Does your child have friends? Does your child interrupt others when they are talking? What are your child's strengths? Does your child obey you? How would you describe your child's self-esteem?

These questions are not all inclusive nor are they meant to be used as a checklist for diagnosing ADHD. Rather, they are designed to flesh-out the DSM-IV criteria. For example, if I ask a parent if the child is fidgety, the parent may say, "No." However, if I ask if the child is able to sit through dinner in a restaurant, the parent may give a very different response. These more specific responses often provide information that is pertinent to the diagnosis.

Athealth.com: Do you consider one or two of the questions to be more important than the others?

Dr. Gephart: No. All of the questions used in the parent interview are important to learning about the child. However, if you really pressed me to choose a question that seems to describe a significant percentage of ADHD kids, it would be: Does your child do his/her homework and forget to turn it in?

Athealth.com: Describe how you treat a child with ADHD.

Dr. Gephart: Once the diagnosis is made, we develop a child-specific treatment plan that includes goals, methods of treatment, patient education, a system for monitoring progress, and plans for follow-up.

Athealth.com: What do you do if the child does not respond to treatment?

Dr. Gephart: If the target outcomes are not met and the child is not responsive to treatment, we re-group and try to find out why. This means reassessing the original diagnosis, evaluating the selection of medications, looking to see if all appropriate treatments have been tried, examining compliance issues, and determining if there is a co-occurring condition that we may have missed.

Athealth.com: Does the presence of ADHD in a child pose particular problems for other members of the family?

Dr. Gephart: Parents of ADHD children have a higher incidence of depression and alcohol-related disorders and are at greater risk for marital problems. Dealing with an ADHD child can place a considerable amount of stress on a family, particularly if the child's symptoms are severe. If sibling relationships are poor (and they often are), the strain on the family is increased. It is not uncommon for more than one child in a family to have the disorder.

Because ADHD is a chronic condition, families who have an ADHD child may be in for a long haul, and they have to develop long-term coping skills. Single parents are particularly hard hit since they are alone on the front line.

In addition, the disorder places a financial burden on families. Evaluation and treatment can be costly, and work schedules and careers sometimes have to be adjusted to meet the child's needs.

Athealth.com: What are some of the most significant developments in the treatment of ADHD in recent years?

Dr. Gephart:

• Despite it's limitations, the development of the DSM-IV criteria for diagnosing ADHD;
• The development of practice guidelines that help us do a better job of assessing and treating ADHD; and
• The introduction of longer-acting medications. For example, once-a-day medications help reduce the social stigma associated with ADHD because they eliminate the need to interrupt after-school activities or single out the child for a trip to the nurse's office to receive his/her medication.

Athealth.com: Are there areas that still need improvement?

Dr. Gephart: Always. We need to develop a better understanding of ADHD in girls. Additional research needs to be done with regard to the diagnosis and treatment of ADHD in adolescents. Also, there is very little information in the literature on ADHD and multicultural issues, and I hope to see some research generated in this area.

Athealth.com: Thank you for taking time to share your expertise with us.

Copyright © At Health, Inc.

Page last modified or reviewed by athealth.com on February 3, 2014

Self-Esteem - Definition

Even though a vast quantity of theory, research, and commentary on the construct of self-concept has been produced since William James first introduced the notion more than one hundred years ago, the construct and its manifestations remain elusive. As Harter (1983) points out, constructs that are related to the construct of self-concept are also usually described by hyphenated terms such as self-worth, self-esteem, self-assurance, and self-regard.

Bednar, Wells, and Peterson (1989) define self-esteem "as a subjective and realistic self-approval" (p. 4). They point out that "self-esteem reflects how the individual views and values the self at the most fundamental levels of psychological experiencing" (p. 4) and that different aspects of the self create a "profile of emotions associated with the various roles in which the person operates...and [that self-esteem] is an enduring and affective sense of personal value based on accurate self-perceptions." According to this definition, low self-esteem would be characterized by negative emotions associated with the various roles in which a person operates and by either low personal value or inaccurate self-perceptions.

Furthermore, Bednar et al. describe paradoxical examples of individuals of substantial achievement who report deep feelings of low self-esteem. The authors suggest that a theory of self-esteem must take into account the important role of an individual's "self-talk and self-thoughts" as well as the perceived appraisal of others (p. 11). They conclude that "high or low levels of self-esteem...are the result and the reflection of the internal, affective feedback the organism most commonly experiences" (p. 14). They point out that all individuals must experience some negative feedback from their social environment, some of which is bound to be valid. Thus a significant aspect of the development and maintenance of self-esteem must address how individuals cope with negative feedback.

Bednar et al. suggest that, if individuals avoid rather than cope with negative feedback, they have to devote substantial effort to "gain the approval of others by impression management, that is, pretending to be what we believe is most acceptable to others" (p. 13; italics theirs). If individuals respond to negative feedback by striving to manage the impressions they make on others to gain their approval, they also have to "render most of the favorable feedback they receive [as] untrustworthy, unbelievable, and psychologically impotent because of their internal awareness of their own facade" (p. 13). This preoccupation with managing the impression one makes on others is a behavior characteristic usually included in definitions of narcissism.

Developmental Considerations

For very young children, self-esteem is probably best thought to consist of deep feelings of being loved, accepted, and valued by significant others rather than of feelings derived from evaluating oneself against some external criteria, as in the case of older children. Indeed, the only criterion appropriate for accepting and loving a newborn or infant is that he or she has been born. The unconditional love and acceptance experienced in the first year or two of life lay the foundation for later self-esteem, and probably make it possible for the preschooler and older child to withstand occasional criticism and negative evaluations that usually accompany socialization into the larger community.

As children grow beyond the preschool years, the larger society imposes criteria and conditions upon love and acceptance. If the very early feelings of love and acceptance are deep enough, the child can most likely weather the rebuffs and scoldings of the later years without undue debilitation. With increasing age, however, children begin to internalize criteria of self-worth and a sense of the standards to be attained on the criteria from the larger community they observe and in which they are beginning to participate. The issue of criteria of self-esteem is examined more closely below.

Cassidy's (1988) study of the relationship between self-esteem at age five and six years and the quality of early mother-child attachment supports Bowlby's theory that construction of the self is derived from early daily experience with attachment figures. The results of the study support Bowlby's conception of the process through which continuity in development occurs, and of the way early child-mother attachment continues to influence the child's conception and estimation of the self across many years. The working models of the self derived from early mother-child inter-action organize and help mold the child's environment "by seeking particular kinds of people and by eliciting particular behavior from them" (Cassidy, 1988, p. 133). Cassidy points out that very young children have few means of learning about themselves other than through experience with attachment figures. She suggests that if infants are valued and given comfort when required, they come to feel valuable; conversely, if they are neglected or rejected, they come to feel worthless and of little value.

In an examination of developmental considerations, Bednar, Wells, and Peterson (1989) suggest that feelings of competence and the self-esteem associated with them are enhanced in children when their parents provide an optimum mixture of acceptance, affection, rational limits and controls, and high expectations. In a similar way, teachers are likely to engender positive feelings when they provide such a combination of acceptance, limits, and meaningful and realistic expectations concerning behavior and effort (Lamborn et al., 1991). Similarly, teachers can provide contexts for such an optimum mixture of acceptance, limits, and meaningful effort in the course of project work as described by Katz and Chard (1989).

Many teachers feel compelled to employ the questionable practices described above as strategies to help children who seem to them not to have had the kind of strong and healthy attachment experiences in their early years that support the development of self-esteem. While such children may not be harmed by exercises that tell them they are special or by constant praise and flattery, the argument here is that they are more likely to achieve real self-esteem from experiences that provide meaningful challenge and opportunities for real effort.

The Cyclic Nature of Self-Esteem

The relationships between self-evaluation, effort, and reevaluation of the self suggest a cyclic aspect to the dynamics of self-esteem. Harter (1983) asserts that the term self-worth is frequently used to refer to aspects of motivation and moods. High self-esteem is associated with a mood of cheerfulness, feelings of optimism, and relatively high energy. Low self-esteem is accompanied by feelings of doubt about one's worth and acceptability, and with feeling forlorn, morose, or even sad. Such feelings may be accompanied by relatively low energy and weak motivation, invariably resulting in low effort. In contrast, high self-esteem is associated with high energy, which increases effectiveness and competence, which in turn strengthen feelings of self-esteem and self-worth. In this way, feelings about oneself constitute a recursive cycle such that the feelings arising from self-appraisal tend to produce behavior that strengthens those feelings-both positive and negative.

The cyclic formulation of self-esteem is similar to Bandura's (1989) conception of self-efficacy, namely, processes by which perceptions of one's own capacities and effective action "affect each other bidirectionally" (p. 1176). In other words, effective action makes it possible to see oneself as competent, which in turn leads to effective action, and so forth. The same cycle applies to self-perceptions of incompetence. However, Bandura (1989) warns that a sense of personal efficacy [does] not arise simply from the incantation of capability. Saying something should not be confused with believing it to be so. Simply saying that one is capable is not necessarily self-convincing, especially when it contradicts preexisting firm beliefs. No amount of reiteration that I can fly will persuade me that I have the efficacy to get myself airborne and to propel myself through the air. (p. 1179)

This formulation of the dynamics of feelings about the self confirms the view that self-esteem merits the concern of educators and parents. Nevertheless, it also casts some doubt on the frequent assertion that, if children are somehow made to "feel good about themselves," success in school will follow. In other words, just because young children need to "feel good about themselves," telling them that they are special (e.g., because they can color) or that they are unique, and providing them with other similar flattery may not cause them to believe they are so or engender in them good feelings about themselves.

Dunn's (1988) view of the nature of self-esteem is that it is related to the extent to which one sees oneself as the cause of effects. She asserts that "the sense of cause [is] a crucial feature of the sense of self" and the essence of self-confidence is the feeling of having an effect on things and being able to cause or at least affect events and others. On the other hand, feeling loved by the significant others in one's environment involves feeling and knowing that one's behavior and status really matter to them-matter enough to cause them to have real emotion and to provoke action and reaction from them, including anger and stress as well as pride and joy.

Criteria of Self-Esteem

It is reasonable to assume that self-esteem does not exist in a vacuum, but is the product of evaluating oneself against one or more criteria and reaching expected standards on these criteria. These evaluations are unlikely to be made consciously or deliberately, but by means of preconscious or intuitive thought processes. It is likely that these criteria vary not only between cultures and subcultures, but also within them. The criteria may also vary by gender. Furthermore, the standards within a family, subculture, or culture that have to be met on these criteria may also vary by gender. For example, higher standards on a criterion of assertive-ness may be required for self-esteem in males than in females. In addition, the criteria against which the worth and acceptability of an individual are estimated may carry different weights across cultures, subcultures, and families, and for the sexes. Criteria may have different weighting for different families, some giving more weight in their total self-esteem to physical appearance, and others to personal traits or teacher acceptance, for example.

Criteria for self-esteem frequently employed in American self-concept research include physical appearance, physical ability, achievement, peer acceptance, and a variety of personal traits (Harter, 1983). As is indicated in the discussion below, Western and Eastern cultures vary in how the self is defined and the criteria against which the self is estimated. These sources of variation imply that some children are likely to have acquired criteria of self-esteem at home and in their immediate community that differ from those assumed valuable in the classroom and in the school.

One of the many challenges teachers face in working with young children of diverse backgrounds is to help them understand and come to terms with the criteria of self-esteem applicable in the class and school without belittling the criteria advocated and applied at home. While it is not appropriate for schools to challenge the criteria or standards of self-esteem of children's families, careful consideration of those self-esteem criteria advocated within the school is warranted.

To the extent that one's self-esteem is based on competitive achievement, it can be enhanced by identifying other individuals or groups who can be perceived as lower or inferior to oneself in achievement. If, for example, schools convey to children that their self-esteem is related to their academic achievement as indicated by the results of competitive grading practices, then a significant proportion of children, ipso facto, must have low self-esteem-at least on that criterion. In such a school culture the development of cooperation and intergroup solidarity becomes very problematic. Also, if competitive academic achievement is highly weighted among not only the school's criteria of self-esteem but also the criteria of the culture as a whole, a substantial proportion of school children may be condemned to feel inadequate. An adaptive response of children at the low end of the distribution of academic achievement might be to distance themselves from that culture and to identify and strive to meet other criteria of self-esteem, such as the criteria of various peer groups, that may or may not enhance participation in the larger society. To avoid these potentially divisive effects of such competitive and comparative self-evaluations, the school should provide contexts in which all participants can contribute to group efforts, albeit in individual ways. A substantial body of research indicates that cooperative learning strategies and cooperative goals are effective ways to address these issues (see Ames, 1992).

The matter of what constitute appropriate criteria of self-esteem cannot be settled empirically by research or even theory. These criteria are deeply imbedded within a culture, promoted and safeguarded by the culture's religious, moral, and philosophical institutions.

Although, as stated earlier, it is important to value an infant simply for the fact that he or she has been born, if criteria for self-esteem that are applied later in the child's life include characteristics that are present at birth-such as one's nationality, race, or gender-then the ability of all citizens to achieve self-esteem in a society of diverse groups, especially when one group is culturally or otherwise dominant, is problematic. Furthermore, as suggested above, if children are taught to base their self-appraisals on favorable comparisons of themselves with others, then the identification of inferior others, whether individuals or groups, may become endemic in a society. When the two tendencies-to base self-esteem on characteristics that are present at birth and to elevate one's self-appraisal by identifying others who are inferior on any given criterion-occur together in a society, conditions develop which are likely to support prejudice and oppression.

If, on the other hand, the criteria address personal attributes that are susceptible to individual effort and intention, such as contributing to one's community, then all citizens have the potential to achieve feelings of self-worth, self-respect, and dignity. Thus, while a person's nationality might not be an appropriate basis of self-esteem, accepting responsibility for the conduct of one's nation in the world and contributing to the welfare of one's nation might be appropriate bases for positive self-appraisal. In any case, the designation of appropriate criteria is not primarily the responsibility of educators, but of the moral institutions of the community and culture at large that educators are duty-bound to support.

This view that nationality in and of itself may be a faulty basis for self-esteem is not to deny the value and desirability of love of country or patriotism, both of which contribute to involvement in the country's welfare. Nor should this view be interpreted as belittling civic and national pride, which can motivate and mobilize efforts to work on behalf of one's community and country.

A related issue is the role of reflected glory in self-esteem, which has both apparently inappropriate and potentially beneficial effects. Should individuals' self-esteem be influenced by the performance of their hometown football team or their country's Olympic teams? According to research on "basking in reflected glory" (BIRGing) reported by Cialdini (1974, 1976), Lee (1985), and Kowalski (1991), the tendency to strengthen one's association with those who are visibly successful and to distance oneself from those who have experienced obvious failures as means of self-enhancement is a common phenomenon. Inasmuch as a sports fan makes no real contribution to the team's performance, that performance would seem to be an inappropriate source of either pride or shame and of fluctuations in the fan's self-esteem. On the other hand, the capacity to experience reflected glory and reflected shame might provide powerful motivation for community action. Action on behalf of one's community would seem to be a legitimate basis for self-esteem.

While the issues are complex, the main argument here is that if personal attributes that are present by virtue of birth alone, without individual effort and contribution, are a source of self-esteem beyond the first few years of life, individuals born without these attributes must see themselves as lacking or low in self-worth; therefore, such attributes seem to be inappropriate criteria for self-esteem.

Situational Determinants of Self-Esteem

Bednar, Wells, and Peterson (1989) state that there may be a "situated" as well as a "general" self-identity (p. 39), suggesting that self-esteem may vary from one interpersonal situation to another. In other words, although the overall context of experience may remain constant, changes in interpersonal situations can cause reassessments of the self. For example, a teacher might have a fairly high estimation of herself in the context of teaching her own class, but when the interpersonal situation changes by the entrance of a colleague or the principal or a parent, she may shift her estimation or self-rating-probably downward! Although the teacher is exactly the same person five minutes before the intrusion as she is five minutes afterwards, the change in self-esteem is created by the teacher herself when she attributes greater significance to the other's assessment of herself than to her own assessment. On the other hand, if the other person's assessment is based on greater knowledge, experience, and expertise, the teacher could consider herself informed or instructed by that assessment rather than simply accorded lower esteem.

Shifts in self-estimation based on the assessments of significant others may be developmentally appropriate for young children. In an adult, however, revision of self-estimation based on the perceived or imagined assessments of another adult that are at variance with one's own requires placing oneself in the role of child with respect to the other adult. The essence of self-esteem for mature adults is to take seriously the assessments of others, but not to take them more seriously than they take their own self-assessments.

While adults can seek contexts and interpersonal situations that maximize their self-esteem and can strive to avoid those that minimize it, children are at the mercy of the situations in which adults place them. Inasmuch as young children vary in background, abilities, culture, and so forth, a wide rather than narrow range of interpersonal situations should be provided for them. In other words, an early childhood program is most likely to enhance children's self-esteem and their capacities to deal with inevitable fluctuations in self-esteem when a variety of types of interpersonal situations is available to them.

Rosenholtz and Simpson (1984) addressed this issue in terms of the variety of dimensions of children's behavior to which teachers assign importance in a classroom. They define classes in which a limited range of child behavior is accepted, acknowledged, and rewarded as unidimensional. Multidimensional classes are those in which teachers provide a wide range of ways for children to contribute to and participate in the classroom life and in which a range of behavior is accepted, rewarded, and acknowledged. Rosenholtz and Simpson suggest that the unidimensional classroom limits opportunity for self-enhancement, and the multidimensional classroom makes it possible for many if not all pupils to find ways to enhance their feelings of self-esteem and self-worth. Multidimensionality in the classroom can be fostered when teachers include as part of the curriculum the kinds of projects described by Katz and Chard (1989) in which a wide range of activities of intellectual, social, aesthetic, and artistic value is included.

Cultural Variations

Markus and Kitayama (1991) point out that the construal of the self varies among cultures and that Americans and other Westerners typically construe the self as an independent, bounded, unitary, stable entity that is internal and private. On the other hand, they assert that in non-Western cultures such as those in Asia and Africa the self is construed as interdependent, connected with the social context, flexible, variable, external, and public. Westerners view the self as an autonomous entity consisting of a unique configuration of traits, motives, values, and behaviors. The Asian view is that the self exists primarily in relation to others, and to specific social contexts, and is esteemed to the extent that it can adjust to others, maintain harmony, and exercise the kind of restraint that will minimize social disruption.

According to Markus and Kitayama (1991), these contrasting culture-bound construals of the self have significant consequences for cognition, affect, and motivation. Asian children must learn that positive feelings about the self should derive from fulfilling tasks associated with the well-being of relevant others. On the other hand, Western children have to learn that the self consists of stable dispositions or traits and that "they must try to enhance themselves whenever possible...taking credit for success...explaining away their failures, and in various ways try to aggrandize themselves" (p. 242). Eventually American children must learn that "maintaining self-esteem requires separating oneself from others and seeing oneself as different from and better than others" (p. 242). According to this formulation, Americans cannot perceive themselves as better than others without describing the others as worse than themselves. When one's own self-esteem is the result of comparison processes, its maintenance may contribute to constant wariness of the risk of coming out poorly in such comparative assessments of self-worth. At worst, such sources of self-esteem may contribute to a need to identify lesser or inferior others-either individuals or groups. At best, they may contribute to excessive competitiveness and may distract individuals from giving their full attention to the tasks at hand, thereby depressing their learning and effectiveness. Developmental studies reviewed by Markus and Kitayama (1991) indicate that self-enhancement and self-promotion are perceived negatively in Japan and that, although not apparent in the early years, by fifth grade Japanese children have learned that it is unwise to gloat over their accomplishments or to express confidence in their own ability. Research indicates that as children are socialized in an interdependent cultural context, they begin to appreciate the cultural value of self-restraint and, furthermore, to believe in a positive association between self-restraint and other favorable attributes of the person not only in the social, emotional domains but also in the domains of ability and competence. (p. 242)

The distinctions between the Western independent and the non-Western interdependent construal of the self indicate that the sources of self-esteem are also distinctive. For Westerners, independent self-esteem is achieved by actualizing one's own attributes, having one's accomplishments validated by others, and being able to compare oneself to others favorably. In Asian and other non-Western cultures, self-esteem is related to self-restraint, modesty, and connectedness with others. Stevenson and his colleagues (Stevenson, Lee, Chen, Lummis, Stigler, Fan, & Ge, 1990; Stevenson, Lee, Chen, Stigler, Hsu, & Kitamura, 1990) have noted that American children appear to have more positive conceptions of their mathematical abilities than Asian children do, even though the latter actually perform much better than the former. Such findings must be interpreted in light of the cultural differences of the two groups. Asian children apparently learn early that pride in one's strengths is interpreted as gloating and is unacceptable; American children are encouraged to be proud of their accomplishments. Frequent exhortations to "feel good about oneself" and to see oneself as "special" may contribute to the unrealistic self-appraisals reported by Stevenson and his colleagues.

Along similar lines, Trafimow, Triandis, and Goto (1991) distinguish between private and collective aspects of the self, arguing that the private self is emphasized more in individualistic cultures such as in North America and parts of Europe and that the collective aspects of the self are emphasized more in collectivistic cultures such as those of East Asia. These contrasts suggest that, while self-esteem seems to be important in all cultures, it is achieved in diverse ways in different cultures.

The practices described earlier in this discussion that are intended to help children achieve and maintain high self-esteem (e.g., "All About Me" books and "I am Special" celebrations) may inadvertently cultivate narcissism-not in its pathological form as the term is used in psychiatric diagnoses, but as a general disposition. These school practices may be symptomatic of our larger culture, described by several observers as having many of the attributes of a narcissistic society (Lasch, 1979; Wallach & Wallach, 1985). Lowen (1985) claims that when success is more important than self-respect, the culture itself overvalues image and is narcissistic, and further that narcissism denotes a degree of unreality in individuals and the culture.

Our culture seems almost obsessed with the image one projects to others. Many of our political leaders use expressions like not wanting their actions "to appear to be improper" rather than not wanting them to be improper. At the beginning of the Gulf War crisis, President Bush said, "We have to appear to be strong" rather than that we have to be strong, suggesting that momentous decisions are based as much or more upon appearances than upon actualities. The term impression management has indeed entered into the national vocabulary!

A related manifestation of confusing images with reality is explored thoughtfully by Kakutani under the heading "Virtual Confusion: Time for a Reality Check." Kakutani (1992) points out that "ardent soap opera viewers routinely confuse their favorite characters with the actors who play them...and send 'CARE' packages to actors who play impoverished characters" (p. B2).

Narcissism - Definition

According to Lowen (1985), narcissism refers to a syndrome characterized by exaggerated investment in one's own image versus one's true self and in how one appears versus how one actually feels. Dispositions often mentioned in definitions of narcissism as being characteristic of narcissism include dispositions to behave in seductive and manipulative ways, to strive for power, and to sacrifice personal integrity for ego needs. Adults diagnosed as suffering from the narcissism syndrome often complain that their lives are empty or meaningless, and they often show insensitivity to the needs of others. Their behavior patterns suggest that notoriety and attention are more important to them than their own dignity.

According to Emmons (1987), narcissism is characterized by being self-absorbed, self-centered, or selfish, even to the extent that it "may lessen individuals' willingness to pursue common social objectives...[and] increase potential for social conflict...on a group level" such as occurs with "excessive ethnocentrism" (p. 11). As part of the definition of narcissism in adults, Emmons refers to the tendency to "accept responsibility for successful outcomes and deny blame for failed outcomes" (p. 11). According to some specialists, narcissism includes a preoccupation with fantasies about unlimited success, power, and beauty, plus a grandiose sense of self-importance. Raskin, Novacek, and Hogan (1991) interpret their experimental findings to mean that narcissistic behaviors are defenses against, or defensive expression of, threatening emotions such as anger, anxiety, and fear. Anger, hostility, and rage seem central to the emotional life of the narcissist; consequently, narcissistic behaviors may allow the expression of these emotions in a way that protects a sense of positive self-regard. (p. 917)

Narcissists are also sometimes described as exhibitionistic, requiring constant attention and admiration, often believing that they are entitled to special favors without the need to reciprocate. They tend to exploit others, to be seekers of sensations, experiences, and thrills, and to be highly susceptible to boredom. Many of these characteristics of narcissism seem to apply to our culture in general and to many of our youth in particular.

Wink (1991) suggests that narcissism takes at least two major forms. The classical form is indicated by excessive need for admiration, frequent exhibitionism, conceit, and a tendency toward open expression of grandiosity-commonly referred to as "being a bit too full of oneself." Wink calls the second form "covert narcissism," in which individuals "appear to be hypersensitive, anxious, timid, and insecure; but on close contact surprise others with their grandiose fantasies" (p. 591). They tend to be exploitative and to over-interpret others' behavior as caused by or directed to themselves rather than to others.

In sum, healthy self-esteem refers to realistic and accurate positive appraisals of the self on significant criteria across a variety of interpersonal situations. It also includes the ability to cope with the inevitability of some negative feedback. By contrast, unhealthy self-esteem, as in narcissism, refers to insensitivity to others, with excessive preoccupation with the self and one's own image and appearance in the eyes of others.

Adapted from: Distinctions between Self-Esteem and Narcissism: Implications for Practice
Author: Lilian G. Katz
October 1993
Accessed: http://ceep.crc.uiuc.edu/eecearchive/books/selfe.html [2009, January 8].

Page last modified or reviewed by athealth.com on February 3, 2014

During the past two decades, a convincing body of evidence has accumulated to indicate that unless children achieve minimal social competence by about the age of 6 years, they have a high probability of being at risk into adulthood in several ways (Ladd, 2000; Parker & Asher, 1987). Recent research (Hartup & Moore, 1990; Kinsey, 2000; Ladd & Profilet, 1996; McClellan & Kinsey, 1999; Parker & Asher, 1987; Rogoff, 1990) suggests that a child's long-term social and emotional adaptation, academic and cognitive development, and citizenship are enhanced by frequent opportunities to strengthen social competence during childhood.

Hartup (1992) notes that peer relationships in particular contribute a great deal to both social and cognitive development and to the effectiveness with which we function as adults. He states that "the single best childhood predictor of adult adaptation is not school grades, and not classroom behavior, but rather, the adequacy with which the child gets along with other children. Children who are generally disliked, who are aggressive and disruptive, who are unable to sustain close relationships with other children, and who cannot establish a place for themselves in the peer culture are seriously at risk" (Hartup, 1992, p. 1). The risks are many: poor mental health, dropping out of school, low achievement and other school difficulties, and poor employment history (Katz & McClellan, 1997).

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.

Because social development begins at birth and progresses rapidly during the preschool years, it is clear that early childhood programs should include regular opportunities for spontaneous child-initiated social play. Berk and Winsler (1995) suggest that it is through symbolic/pretend play that young children are most likely to develop both socially and intellectually. Thus, periodic assessment of children's progress in the acquisition of social competence is appropriate.

The set of items presented below is based on research on elements of social competence in young children and on studies in which the behavior of well-liked children has been compared with that of less-liked children (Katz & McClellan, 1997; Ladd & Profilet, 1996; McClellan & Kinsey, 1999).

The Social Attributes Checklist

The checklist provided in this digest includes attributes of a child's social behavior that teachers are encouraged to examine every three or four months. Consultations with parents and other caregivers help to provide a validity check. In using the checklist, teachers are advised to note whether the attributes are typical of the child. Any child can have a few really bad days, for a variety of reasons; if assessments are to be reasonably reliable, judgments of the overall pattern of functioning over a period of at least three or four weeks are required. The checklist is intended as one of a variety of ways the social well-being of children can be assessed.

How children act toward and are treated by their classmates (cooperatively or aggressively, helpfully or demandingly, etc.) appears to have a substantial impact on the relationships they develop (Ladd, 2000). However, healthy social development does not require that a child be a "social butterfly." The most important index to note is the quality rather than the quantity of a child's friendships. Children (even rejected children) who develop a close friend increase the degree to which they feel positively about school over time (Ladd, 1999). There is evidence (Rothbart & Bates, 1998; Kagan, 1992) that some children are simply more shy or more inhibited than others, and it may be counterproductive to push such children into social relations that make them uncomfortable (Katz & McClellan, 1997). Furthermore, unless that shyness is severe enough to prevent a child from enjoying most of the "good things of life," such as birthday parties, picnics, and family outings, it is reasonable to assume that, when handled sensitively, the shyness will be spontaneously outgrown.

Many of the attributes listed in the checklist below indicate adequate social growth if they characterize the child's usual behavior. This qualifier is included to ensure that occasional fluctuations do not lead to over-interpretation of children's temporary difficulties. On the basis of frequent direct contact with the child, observation in a variety of situations, and information obtained from parents and other caregivers, a teacher or caregiver can use the checklist as an informal research-based means of assessing each child's social and emotional well-being. It is intended to provide a guideline for teachers and parents and is based on several teacher rating scales (all demonstrating high internal reliability) used by researchers to measure children's social behavior. Most of these scales (Ladd, 2000; Ladd & Profilet, 1996; McClellan & Kinsey, 1999) have also been replicated on more than one occasion and have demonstrated high reliability over time.

Teachers can observe and monitor interactions among children and let children who rarely have difficulties attempt to solve conflicts by themselves before intervening. If a child appears to be doing well on most of the attributes and characteristics in the checklist, then it is reasonable to assume that occasional social difficulties will be outgrown without intervention. It is also reasonable to assume that children will strengthen their social skills, confidence, and independence by being entrusted to solve their social difficulties without adult assistance. However, if a child seems to be doing poorly on many of the items listed, the responsible adults can implement strategies that will help the child to overcome and outgrow the social difficulties. The checklist is not a prescription for "correct social behavior"; rather it is an aid to help teachers observe, understand, and support children as they grow in social skillfulness. If a child seems to be doing poorly on many of the items on the list, strategies can be implemented to help the child to establish more satisfying relationships with other children (Katz & McClellan, 1997).

Children's current and long-term social-emotional development, as well as cognitive and academic (Kinsey, 2000) development, are clearly affected by the child's social experiences with peers and adults. It is important to keep in mind that children vary in social behavior for a variety of reasons. Research indicates that children have distinct personalities and temperaments from birth (Rothbart & Bates, 1998; Kagan, 1992). In addition, nuclear and extended family relationships and cultural contexts also affect social behavior. What is appropriate or effective social behavior in one culture may not be in another. Many children thus may need help in bridging their differences and in finding ways to learn from and enjoy the company of one another. Teachers have a responsibility to be proactive in creating a classroom community that accepts and supports all children.

The Social Attributes Checklist

I. Individual AttributesThe child:

• Is usually in a positive mood.
• Is not excessively dependent on adults.
• Usually comes to the program willingly.
• Usually copes with rebuffs adequately.
• Shows the capacity to empathize.
• Has positive relationships with one or two peers; shows the capacity to really care about them and miss them if they are absent.
• Displays the capacity for humor.
• Does not seem to be acutely lonely.

II. Social Skills AttributesThe child usually:

• Approaches others positively.
• Expresses wishes and preferences clearly; gives reasons for actions and positions.
• Asserts own rights and needs appropriately.
• Is not easily intimidated by bullies.
• Expresses frustrations and anger effectively and without escalating disagreements or harming others.
• Gains access to ongoing groups at play and work.
• Enters ongoing discussion on the subject; makes relevant contributions to ongoing activities.
• Takes turns fairly easily.
• Shows interest in others; exchanges information with and requests information from others appropriately.
• Negotiates and compromises with others appropriately.
• Does not draw inappropriate attention to self.
• Accepts and enjoys peers and adults of ethnic groups other than his or her own.
• Interacts nonverbally with other children with smiles, waves, nods, etc.

III. Peer Relationship AttributesThe child:

• Is usually accepted versus neglected or rejected by other children.
• Is sometimes invited by other children to join them in play, friendship, and work.
• Is named by other children as someone they are friends with or like to play and work with.

Resources

Berk, L., & Winsler, A. (1995). Scaffolding children's learning: Vygotsky and early childhood education. Washington, DC: National Association for the Education of Young Children. ED 384 443.

Halberstadt, A. G., Denham, S. A., & Dunsmore, J. C. (2001). Affective social competence. Social Development, 10(1), 79-119.

Hartup, W. W. (1992). Having friends, making friends, and keeping friends: Relationships as educational contexts. ERIC Digest. Champaign, IL: ERIC Clearinghouse on Elementary and Early Childhood Education. ED 345 854.

Hartup, W. W., & Moore, S. G. (1990). Early peer relations: Developmental significance and prognostic implications.Early Childhood Research Quarterly, 5(1), 1-18. EJ 405 887.

Kagan, J. (1992). Yesterday's premises, tomorrow's promises. Developmental Psychology, 28(6), 990-997. EJ 454 898.

Katz, L. G., & McClellan, D. E. (1997). Fostering children's social competence: The teacher's role. Washington, DC: National Association for the Education of Young Children. ED 413 073.

Kinsey, S. J. (2000). The relationship between prosocial behaviors and academic achievement in the primary multiage classroom. Unpublished doctoral dissertation, Loyola University, Chicago.

Ladd, G. W. (1999). Peer relationships and social competence during early and middle childhood. Annual Review of Psychology, 50, 333-359.

Ladd, G. W. (2000). The fourth R: Relationships as risks and resources following children's transition to school.American Educational Research Association Division E Newsletter, 19(1), 7, 9-11.

Ladd, G. W., & Profilet, S. M. (1996). The child behavior scale: A teacher-report measure of young children's aggressive, withdrawn, and prosocial behaviors. Developmental Psychology, 32(6), 1008-1024. EJ 543 361.

McClellan, D. E., & Kinsey, S. (1999) Children's social behavior in relation to participation in mixed-age or same-age classrooms. Early Childhood Research & Practice [Online], 1(1).

Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low-accepted children at risk?Psychological Bulletin, 102(3), 357-389.

Rogoff, B. M. (1990). Apprenticeship in thinking: Cognitive development in social context. New York: Oxford University Press.

Rothbart, M., & Bates, J. (1998). Temperament. In W. Damon (Series Ed.) & N. Eisenberg (Vol. Ed.), Handbook of child psychology: Vol. 3. Social, emotional, and personality development (5th ed., pp. 105-176). New York: Wiley

Source: EDO-PS-01-2
Authors: Diane E. McClellan and Lilian G. Katz
March 2001

Page last modified or reviewed by athealth on January 29, 2014

Section I - Core Concepts That Guide Screening, Diagnosis and Assessment

Major advancements in the sciences of early identification and treatment of ASD have increased public awareness and focused more attention on this class of neurodevelopmental disorders. The core concepts that follow provide guidance for all professionals in the state of California who are responsible for the screening, diagnostic evaluation and/or assessment for intervention planning for persons with ASD. These core concepts suggest a common language by which both professionals and parents can communicate with each other. Importantly, they also provide referring parties with information about what they can expect from well-informed diagnostic and treatment planning teams.

These Guidelines represent wide collaboration and consensus from expert panels across the state of California regarding screening, evaluation and interdisciplinary assessment for individuals who may meet diagnostic criteria for autistic spectrum disorder. Variables considered by the panels in developing these Guidelines included current scientific knowledge, level of expertise needed to execute a particular function, pragmatics of clinical practice and respect for the family ecology.

The DSM-IV is the current classification standard for establishing a diagnosis of ASD.

The Diagnostic and Statistical Manual, 4th edition (DSM-IV) and the Diagnostic and Statistical Manual, 4th edition, Text Revision (DSM-IV, TR) published by the American Psychiatric Association (1994 and 2000) are the current standards for the diagnosis and classification of ASD. In clinical practice, the DSM-IV is a tool to inform clinical judgment. Its use requires specialized training that provides a body of knowledge and clinical skills (American Psychiatric Association, 1994). Derivation of a differential diagnosis between the ASD and other alternative psychiatric or developmental disorders should employ the DSM-IV criteria for analysis and clarification of diagnostic impressions.

Early identification is essential for early therapeutic intervention and leads to a higher quality of life for the child and family.

Numerous studies on early intervention outcome have delineated the benefits of early identification and intervention for children with developmental disabilities and, particularly, for those with difficulties on the autistic spectrum (Dawson & Osterling, 1997; Harris & Delmolino, 2002; Smith, 1999; Committee on Educational Interventions for Children with Autism, 2001). Strong empirical support exists for the benefits of intensive behavioral programs for young children with autistic spectrum disorders, although the precise teaching strategies and curricula content are often a topic of debate (Dawson & Osterling, 1997; Gresham & MacMillan, 1998; Lovaas, 1987; Ozonoff & Cathcart, 1998; Rogers, 1998; Sheinkopf & Siegel, 1998). While the components of intervention programs are often a source of controversy, it is generally agreed that program intensity combined with early diagnosis and intervention can lead to substantial improvement in child functioning (Harris, 1994b; Sheinkopf & Siegel, 1998).

A substantial benefit of early intervention is the positive impact on the family's ability to interact in a developmentally appropriate manner with their child and to have a greater understanding of the disability and how it interacts with family life (Committee on Children with Disabilities, 1994). Early identification and diagnosis enhances the opportunity for effective educational and behavioral intervention; reduction of family stress by giving the family specific techniques and direction; and access to medical and other supports (Cox, Klein & Charman, 1999). In the end, early intervention improves the quality of life for the individual and his/her family, and is cost efficient for the human service delivery system (Jacobson, Mulick & Green, 1998).

Informed clinical judgment is a required element of a screening, diagnostic and assessment process that leads to accurate identification of and intervention planning for ASD.

In the absence of a single biomedical marker, simple laboratory test or procedure for identifying children who meet the diagnostic criteria for one of the ASD, accurate identification of individuals with ASD is entirely dependent on clinical competencies. For the diagnosis of ASD, the knowledge base must include familiarity and experience with the research literature and with children with ASD. Clinical judgment, based upon knowledge and experience with this population, is critical to the interpretation of DSM-IV criteria for ASD. Access to professionals who possess the necessary levels of clinical competency, such as pediatricians and psychologists, can be found in private health systems, state funded regional centers, and university medical centers.

The screening, diagnosis and assessment of ASD presents different challenges through the individual's life span.

While the core impairments in individuals with autistic disorder are commonly identified in early childhood, other spectrum disorders (PDD-NOS, Asperger's disorder) may be identified much later. Although identification of an ASD is usually made during childhood, it is important to recognize that ASD is a lifelong disability that compromises the individual's adaptive functioning from childhood through adulthood to variable extents, and requires different forms of intervention throughout the lifespan. Assessment should never be viewed as a discrete process, but rather as ongoing, flexible and responsive to changes in the individual's profile caused by intervention effects, maturation, family dynamics and other factors.

Practitioners must be aware of and understand confidentiality issues and honor the need for shared information.

Th[e] Guidelines encourage the use of interdisciplinary teams and interagency collaboration in the screening/early identification, diagnostic evaluation and assessment of individuals suspected of having an ASD. Th[e] Guidelines also recognize that "open" oral and written exchange of information among clinicians and agencies places a grave ethical and legal responsibility on those professionals to share only personal information that is clinically pertinent to the purposes of the intervention. A fully informed written consent at each step in the process is not only an ethical responsibility but a legal one as well. The scope of information shared should be decided on a "need to know" basis. For example, the education system might need specific information from the diagnostic and assessment team about a child's learning strengths and challenges. However, family history regarding psychiatric or other health illness that may be important to the diagnostic process should be held in confidence and not automatically shared with the educational planning team without specific consent. Such discretion can be difficult to manage when parents, for example, are asked to sign multiple releases of confidential information with many providers.

Accurate diagnostic evaluation and assessment requires collaboration and problem solving among professionals, service agencies and families.

Th[e] Guidelines promote interdisciplinary, interagency collaboration and partnership between the referred individual, their family and the service delivery system. It is critical that service providers promote collaboration across disciplines, agencies and programs to resolve conflicts of legal mandates.

Collaborative efforts should be made to avoid duplication of effort and maximize efficient use of time in pursuit of the desired outcomes for the individual and his/her family. Respect for divergent perspectives is necessary to delineate a comprehensive diagnostic profile of children, adolescents and adults with autistic spectrum disorders. Rather than viewing each component of the process as separate, these Guidelines stress establishing linkages among, for example, the primary care provider (PCP), the diagnostic and assessment team and educational planning teams. The diagnostic team, in turn, needs to keep the PCP informed by providing feedback and assisting the PCP in working with the family to ensure appropriate referrals for intervention services, transition planning and family support.

An interdisciplinary process is the recommended means for developing a coherent and inclusive profile of the individual with ASD.

Autistic spectrum disorders affect multiple developmental domains. Therefore, utilizing an interdisciplinary team constitutes best practice for a diagnosis of ASD and is an essential component of the assessment process. An interdisciplinary team is essential for establishing a developmental and psychosocial profile of the child and family to guide intervention planning. Such an approach promotes seamless communication among team members and leads to a more integrated, cohesive translation of findings. The interdisciplinary team creates a view of the individual that is detailed, concrete, easily understood and offers realistic recommendations (Klin, Sparrow, Marans, et al., 2000). A quality interdisciplinary process involves shared leadership, respect, integration and coordination among professionals. Team members recognize that their individual contributions inform construction of the overall picture of the child and that their individual interpretations enable formulation of conclusions and recommendations based upon the combined efforts of the team.

From screening through intervention planning, the evaluation process must be family-centered and culturally sensitive.

A family-centered frame of reference reinforces the concept of parents and caregivers as the most knowledgeable source of information about the child, acknowledges that the child is part of a larger family system and sets the stage for ongoing collaboration and communication between professionals and family members. The needs, priorities and resources of the family should be the primary focus and be respectfully considered during each step of screening, diagnostic evaluation and assessment for intervention planning.

A family-centered frame of reference includes cultural sensitivity and regard for family and community diversity of cultural values, language, religion, education, socio-economic and social-emotional factors that influence coping and conceptualization of the individual with ASD. Maintenance of family involvement should remain at the forefront of interactions in keeping with the concept of family as an equal partner in the diagnostic, assessment and intervention processes.

Timely referral and coordination of evaluation and ongoing assessment enhances outcome.

The diagnostic and assessment process should proceed in a timely manner to expedite the provision of services to the individual and family. Referring professionals should be familiar with options within the individual's geographic area and serve as the communication bridge with service providers to minimize service delays and duplicative efforts. While a child may receive a diagnosis at a young age, a comprehensive profile of skills and deficits is often not obtained for months (and sometimes years) after diagnosis. This incomplete or absent documentation of skills is problematic for the child, family and community service providers. Parental stress is heightened as parents worry about their child while also spending time and energy trying to arrange for needed intervention services. Timely referral, integration, and coordination of clinical teams and service providers lessens family stress and leads to more streamlined and efficient service delivery.

Rapid developments in the field require regular review of current best practice procedures and up-to-date training.

Rapid developments in conceptualization, measurement and basic research on ASD require a commitment to periodic review of current best practices. The heterogeneity of behavioral expression in ASD across age and developmental status, combined with rapid increases in clinical research and knowledge about the core features of the disorder, necessitate ongoing education and training opportunities for participating clinicians. Major shifts have occurred in scientific thinking about ASD. The knowledge base in ASD is changing so rapidly that parents and professionals face a daily challenge of keeping abreast of new developments. The challenge is to stay current with new methods of evaluation and treatment, learn about and obtain the latest screening tools, and maintain an awareness of local and regional community resources.

Source:

Autistic Spectrum Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment

California Department of Developmental Services: 2002
The Guidelines, a publication of the California Department of Developmental Services, are intended to provide professionals, policymakers, parents and other stakeholders with recommendations based on published research, clinical experience and judgment available about "best practice" for screening, evaluating and assessing persons suspected of having ASD. Complete Guidelines can be found at Autistic Spectrum Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment

Reviewed by athealth on January 29, 2013

"BodyWise fits beautifully with our Girl Power! mission. Smart eating not only builds healthy bodies, it is linked to better school performance, a more positive self-image, and a brighter future. Recent studies suggest that unhealthy eating practices can begin in children as young as 8 years old. Yet, adults who regularly interact with middle-school-aged children are usually not adequately trained to recognize the potential risk factors, signs or symptoms of eating disorders or disordered eating."

-Wanda K. Jones, DrPH, Deputy Assistant
Secretary for Health (Women's Health)

Introduction

The BodyWise Eating Disorders Initiative is a part of the Girl Power! Campaign, conducted by the U.S. Department of Health and Human Services (HHS), which seeks to reinforce and sustain positive values and health behaviors among girls ages 9-14. The HHS Office on Women's Health (OWH) is implementing this initiative to address eating disorders and disordered eating - critical health problems affecting preadolescents.

The BodyWise initiative was developed to provide school personnel and other adults interacting with students ages 9 to 12 with the information and encouragement needed to create environments, policies, and programs that discourage disordered eating. A second objective is to help identify youth who have warning signs of eating disorders. The long-term goal of this initiative is to reduce the risk factors that con-tribute to the development of eating disorders and increase the factors that protect youth, thereby contributing to the prevention of new cases.

The materials in this BodyWise Information Packet on Eating Disorders for Middle School Personnel were developed by health communications specialists in partnership with researchers, clinicians, and educators committed to increasing awareness about eating disorders. In addition, school personnel provided input into the development of these materials by participating in focus group meetings conducted by OWH in ethnically and geographically diverse regions of the country.

The BodyWise packet features information specifically directed to adults working with students in grades five, six, and seven. It addresses the signs and symptoms of eating disorders, steps to take when concerned about students, and ways to create a school environment that discourages disordered eating.

The BodyWise materials seek to connect healthy eating, positive body image, and acceptance of size diversity with favorable learning outcomes. They also encourage school personnel to view disordered eating and eating disorders not in isolation, but in the broader context of health and risk-taking behaviors.

Studies in the last decade show that some disordered eating behaviors are related to other health risk behaviors, including tobacco use, alcohol use, marijuana use, delinquency, unprotected sexual activity, and suicide attempts.¹ The information and suggestions provided throughout the BodyWise packet can be easily integrated into your existing curricula and health promotion activities.

The BodyWise Handbook is one of the components of the BodyWise packet. The handbook includes four sections:

• Understanding Disordered Eating and Eating Disorders - An overview of disordered eating and eating disorders, and a brief definition of terms.
• Key Information for School Personnel - Six main messages for school personnel that form the core of the BodyWise initiative.
• How To Use the BodyWise Information Packet - A description of the materials contained within the BodyWise packet and how they can be used by school personnel.
• Definitions - Detailed definitions of eating disorders, including diagnostic criteria from the American Psychiatric Association.

You are encouraged to reproduce the materials in the BodyWise packet and distribute them to other school personnel, parents, and students.

Understanding Disordered Eating and Eating Disorders

Pre- and early adolescence is a time of physical and psychological change. As young people grow into adulthood, they begin to express their unique identities. Dramatic physical changes - increases in height, weight gains, and sexual maturation - are often accompanied by mood swings, wavering self-esteem, and intense peer pressure.

During these years, young people become increasingly concerned with their appearance. They are exposed to media messages - in music, television, and advertising - that often promote the ideal female body as thin and the ideal male body as muscular.

Because our society is focused on appearance, body image becomes central to young people's feelings of self-esteem and self-worth-over-shadowing qualities and achievements in other aspects of their lives. Young girls start talking about "how they look" and "how much they hate how they look." They may dwell on the "cellulite" in their legs or their not-flat enough stomach and develop a fear of fat - both in their food and on their bodies.

Young people of all ethnic and cultural backgrounds are subject to the influences of the dominant culture. They may associate success or acceptance by their peers with achieving the "perfect" physical standard portrayed by the media. As a result, boys and girls may adopt extreme forms of exercise and bodybuilding.

As their bodies are developing, students may experience teasing or negative comments about their body size or shape from family or friends. Some may encounter sexual or racial discrimination or harassment. Consequently, they may feel shame, dissatisfaction, embarrassment, rejection, or even hatred toward their growing bodies.

Young people may use food as a way of coping with these types of stresses and other pressures in their lives. Some students may attempt to gain a sense of control by carefully regulating what they eat - eating only certain foods or eating very little. Others may overeat "snack foods" and sweets to reduce stress and relieve anxiety.

You may be familiar with one or more of the following scenarios:

• The student who eats only a small amount of each food on her plate because she's afraid of getting fat.
• The adolescent boy or girl who comes home to an empty house and eats whatever snack foods are available.
• The young girl who skips breakfast and lunch, has a candy bar and diet soda after school, finds a way to skip the evening meal with her family-and then goes on a secret eating binge in the evening.
• The wrestler who fasts for 2 days before his match to make weight, then eats nonstop for the next day or two.
• The dancer, gymnast, or cheerleader who refuses meat, eggs, milk, or any foods she imagines might make her fat and unable to perform.
• The bright and confident class president who is teased about the size of her body and begins a fad diet to lose weight.

Body dissatisfaction, fear of fat, being teased, dieting, and using food to deal with stress are major risk factors associated with disordered eating.

 "My clothes weren't right. My parents were weird. I didn't fit in... I raised my hand too often at school... Then, at age 10, it seemed I woke up to a body that filled the room. Men were staring at me, and the sixth-grade boys snapped the one bra in the class. Home after school, I'd watch TV and pace. Munching chips. Talking to the dog. Staring out the window. Eating macaroni. Eating soup. Eating..."²

- Marya's Story

DISORDERED EATING BEHAVIORS

• Skipping meals.
• Restricting food choices to a few "acceptable" items.
• Focusing excessively on avoiding certain foods, particularly foods that contain fat.
• Binge eating, particularly snack foods and sweets.
• Self-induced vomiting.
• Taking laxatives, diuretics (water pills), or diet pills.

Katie, now 14, was in third grade when she began anorexic behaviors. "I compared myself to others and to the commercials on losing weight. And my mom and my friends' moms are always talking about dieting. Then one day this boy and I were kidding around and he said, 'You're fat.' That did it. I just stopped eating and I weighed myself all the time. This went on through fourth and fifth grades." The summer before sixth grade, Katie was put in the hospital.³

Disordered Eating
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. Disordered eating has been termed "restrained," "dysfunctional," or "emotional" eating, as well as "chronic dieting syndrome." It can mean not eating enough. It can also mean eating too much, ignoring natural feelings of fullness.

In contrast, normal eating is controlled by an internal system that regulates the balance between food intake and energy expenditures - so that a person usually eats when hungry and stops when full and satisfied. Normal eating is flexible and includes eating for pleasure and social reasons. In normal eating, a person follows regular habits - typically eating three meals a day and snacks to satisfy hunger. Normal eating provides nourishment for the body, increasing energy and strength, and enhancing health and feelings of wellbeing.4

Students engaged in disordered eating may move back and forth across a continuum, returning to normal eating after bouts of dieting or binge eating. Disordered eating can impair a student's ability to learn when accompanied by undernourishment or preoccupation with thoughts of food, body image, or hunger. Disordered eating can also be an early warning sign of an eating disorder. Susceptible individuals may go on to develop an eating disorder from which they cannot recover alone.

Eating Disorders
An eating disorder is a psychiatric illness with specific criteria that are outlined in the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association (see "Definitions" section).

Eating disorders have both mental and physical components that have serious medical consequences that can disrupt growth and development. Illnesses such as anorexia nervosa, bulimia nervosa, or binge eating disorder, are among the key health issues affecting adolescents and young adults. Nine out of every 10 cases are found among girls and young women. All socioeconomic, ethnic, and cultural groups are affected.

Anorexia Nervosa

Approximately 1 out of every 100 adolescent girls develops anorexia nervosa, a dangerous condition in which people can literally starve themselves to death.5 People with this disorder eat very little even though they are already thin. They have an intense and overpowering fear of body fat and weight gain.

Bulimia Nervosa

Another 2 to 5 out of every 100 young women develop bulimia nervosa, a pattern of eating followed by behaviors such as vomiting, taking laxatives or diuretics (water pills), or over-exercising to rid the body of the food or calories consumed.6 People with bulimia nervosa have a fear of body fat even though their size and weight may be normal.

Binge Eating Disorder

Binge eating disorder, characterized by frequent episodes of uncontrolled eating, is probably the most common eating disorder. It occurs in 10 to 15 percent of mildly obese people.7 The overeating or bingeing is often accompanied by feeling out of control and followed by feelings of depression, guilt, or disgust.

OVEREXERCISING

• Exercises more frequently and more intensely than is required for good health or competitive excellence.
• Gives up time from work, school, and relationships to exercise; likes to exercise alone.
• Exercises despite being injured or ill.
• Defines self-worth in terms of athlet-ic performance.
• Says she or he is never satisfied with a performance or game; does not savor victories.

Overexercising is of particular concern when accompanied by disordered eating, body dissatisfaction, fear of fat, or obsession with weight and food.

Overexercising, often practiced by people who have anorexia and bulimia, is exercising frequently, intensely, or compulsively for long periods of time, primarily to compensate for food eaten recently or to be eaten in the near future. A person who over-exercises might display one or more of the following characteristics:

Sari describes how her eating disorder began. "I was on this diet of 800 calories a day, and I was losing lots of weight. One day I was home alone and I couldn't get the chips in the kitchen cabinet out of my mind. I ate the whole bag - and then half a package of chocolate-covered graham crackers. I was so sick, I threw up. The next time I went on a binge I felt disgusted with myself, but I didn't throw up. So I stuck my finger down my throat. It was so easy to keep my behavior a secret. I'd eat normally in front of everyone and binge when my parents were working, so they never heard me vomiting. And I worked out at least 2 hours every day." 8

Key Information for School Personnel

EATING DISORDERS MAY BEGIN AS DISORDERED EATING BEHAVIORS AT VERY YOUNG AGES

Many studies show that disordered eating behaviors begin as early as 8 years of age, with complaints about body size or shape. The Harvard Eating Disorders Center (HEDC) reports that in a study of children ages 8 to 10, approximately half of the girls and one-third of the boys were dissatisfied with their size. Most dissatisfied girls wanted to be thinner, while about half of dissatisfied boys wanted to be heavier and/or more muscular.9

Many individuals with clinically diagnosed anorexia nervosa and bulimia nervosa remember being teased or recall that their problems first began when they started dieting. Similarly, they recall experiencing body dissatisfaction and/or fear of fat, even though they were within the natural weight range for their age. While only a small percentage of people who diet or express body dissatisfaction develop eating disorders, the beginning of an eating disorder typically follows a period of restrictive dieting, a form of disordered eating for youth.

Binge eating disorder is a newly recognized condition that affects millions of people. People with binge eating disorder have varying degrees of obesity. Most have a long history of repeated efforts to diet and feel desperate about their difficulty in controlling food intake. Binge eating behaviors can begin during childhood.

The middle-school years - grades five, six, and seven - are opportune times to recognize and discourage disordered eating behaviors. Although these behaviors may not constitute a serious illness, they are still unhealthy practices that can affect students' ability to learn. They can also trigger a full-blown eating disorder in a susceptible individual that requires intensive treatment.

SIX KEY BODYWISE MESSAGES

• Eating disorders may begin with disordered eating behaviors at very young ages.
• Students' ability to learn is affected by disordered eating and eating disorders.
• The problem of eating disorders is a mental health as well as a physical health issue.
• Early detection of an eating disorder is important to increase the likelihood of successful treatment and recovery.
• Students of all ethnic and cultural groups are vulnerable to developing eating disorders.
• Each member of a school community can help create an environment that discourages disordered eating and promotes the early detection of eating disorders.

These messages form the core of the BodyWise initiative and are included in the BodyWise information sheets.

This section summarizes key information for school personnel, which has been organized into six main messages:

STUDENTS' ABILITY TO LEARN IS AFFECTED BY DISORDERED EATING AND EATING DISORDERS

A review of research compiled by Tufts University School of Nutrition Science and Policy concludes that undernutrition - even in its "milder" forms - during any period of child-hood can have detrimental effects on the cognitive development of children.¹⁰ Undernutrition has an impact on students' behavior, school performance, and overall cognitive development. Undernourished students are hungry. Being hungry - experienced by everyone on occasion-causes irritability, decreased ability to concentrate, nausea, headache, and lack of energy. Students with disordered eating behaviors may experience these sensations every day. Those who attend school hungry have diminished attention spans and may be less able to perform tasks as well as their nourished peers.

Deficiencies in specific nutrients, such as iron, have an immediate effect on students' memory and ability to concentrate. The effects of short-term fasting on academic performance are well documented. Numerous studies have reported significant improvements in students' academic achievement just from eating breakfast.

When students are not eating well, they can become less active and more apathetic, and interact less with their surrounding environment.¹¹ This in turn affects their social interactions, inquisitiveness, and overall cognitive functioning. In addition, undernourished students are tired and more vulnerable to illness. They are more likely to be absent from school.

Undernourished students may be preoccupied with thoughts of food and weight.

Students with eating disorders share some of the same physical and psychological symptoms as people who have experienced starvation. For example, preoccupation with food was documented in the Minnesota Human Starvation study¹² and, more recently, has been observed in clinical practices with regard to eating disorders.¹³ One of the major effects of starvation and semistarvation appears to be an obsession with food.¹⁴

 "In our clinical practice we surveyed over 1,000 people with clinically diagnosed eating disorders. We found that people with anorexia nervosa report 90 to 100 per-cent of their waking time is spent thinking about food, weight, and hunger; an additional amount of time is spent dreaming of food or having sleep disturbed by hunger. People with bulimia nervosa report spending about 70 to 90 percent of their total conscious time thinking about food and weight-related issues. In addition, people with disordered eating, may spend about 20 to 65 percent of their waking hours thinking about food. By comparison, women with normal eating habits will probably spend about 10 to 15 percent of waking time thinking about food, weight, and hunger."¹⁵ - Dan W. Reiff, MPH, Therapist and Author

"Girls or boys who are self-conscious about their weight and shape, engage in restrictive dieting or excessive exercise, or think of their goals in terms of pounds or fashion models are less interested in and less able to participate in learning." ¹⁶ - Michael Levine, PhD, Professor, Department of Psychology, Kenyon College

"Although students with eating disorders may display deteriorating school performance, anorexic young women often have perfectionist attitudes which enable them to maintain high levels of academic achievement, despite their being seriously malnourished." - Harold Goldstein, PhD, Clinical Director, Eating Disorders Program, National Institutes of Mental Health Therapist and Author

"At the end of the 20tth century, fear of fat, anxiety about body parts, and expectations of perfection in the dressing room have all coalesced to make 'I hate my body' into a powerful mantra that informs the social and spiritual life of too many American girls."¹⁷- Joan Jacobs Brumberg, The Body Project

The problem of eating disorders is a mental health as well as a physical health issue.

Anorexia nervosa, bulimia nervosa, and binge eating disorder are classified as psychiatric illnesses.

The development of eating disorders involves a complex interaction of factors including personality, genetics, environment (familial, social, and cultural), and biochemistry.18 Many people with eating disorders also suffer from other psychiatric illnesses, such as depression, anxiety, and obsessive compulsive disorder.

The National Institute of Mental Health (NIMH) reports that many people with eating disorders share certain characteristics such as low self-esteem, feelings of helplessness, and fear of becoming fat. Eating behaviors in people with anorexia nervosa, bulimia nervosa, and binge eating disorder seem to develop as a way of handling stress and anxieties. Those with anorexia nervosa tend to be "too good to be true." They keep their feelings to themselves, rarely disobey, and tend to be perfectionists, good students, and excellent athletes.

Some researchers believe that people with anorexia nervosa restrict food to gain a sense of control in some area of their lives. Young people with this disease often follow the wishes of others. As a result, they do not learn how to cope with the problems typical of adolescence, growing up, and becoming independent. Controlling their weight may appear to offer two advantages, at least initially: they can take control of their bodies and gain approval from others.

People who develop bulimia nervosa and binge eating disorder typically consume huge amounts of food - often junk food - to reduce stress and relieve anxiety. Feelings of guilt and depression tend to accompany binge eating, while individuals with bulimia nervosa are impulsive and more likely to engage in risky behaviors such as alcohol and drug abuse.

Genetic, behavioral, environmental, and biochemical factors all play a role in the development of eating disorders.

Eating disorders appear to run in families, suggesting that genetic factors may predispose some people to eating disorders. However, other influences may also play a role. Mothers who are overly concerned about their daughters' weight and physical attractiveness may put the girls at increased risk of developing an eating disorder. In addition, girls with eating disorders often have fathers and brothers who are overly critical of their weight. Some researchers link an increase in the rate of disordered eating to increased pressures on women by the mass media, fashion, and diet industry to pursue thinness.¹⁹

In addition, scientists have studied the bio-chemical functions of people with eating disorders and found that many of the neuroendocrine system's regulatory mechanisms are seriously disturbed.

Eating disorders have serious physical consequences that can begin during adolescence

Adolescence is a time of rapid growth and development. Approximately 90 percent of adult bone mass will be established during adolescence.²⁰ Osteoporosis ("porous bones" that break easily) can begin early in both girls and boys who are dieting or suffering from anorexia nervosa. An extended period of starvation or semistarvation stunts growth, can delay the onset of menstruation, and can damage vital organs such as the heart and brain. One in 10 cases of anorexia nervosa leads to death from starvation, cardiac arrest, other medical complications, or suicide.²¹

The vomiting that often accompanies bulimia can erode tooth enamel and damage the esophagus. Using laxatives as a form of purging can result in stomach and colon damage. Both anorexia and bulimia can cause fluid and electrolyte abnormalities, including dehydration and a deficiency in potassium resulting in muscle weakness, irritability, apathy, drowsiness, mental confusion, and irregular heartbeat.

The major complications caused by binge eating disorder are the diseases that accompany obesity, such as heart disease, high blood pres-sure, diabetes, gall bladder disease, and certain types of cancer.

Students engaged in disordered eating behaviors are not well nourished.

Preadolescents need highly nutritious foods to support their rapidly growing and developing bodies. However, students with disordered eating behaviors are likely to consume much less than the recommended daily allowances of many essential nutrients.

Early detection of an eating disorder is important to increate the likelihood of successful treatment and recovery.

During adolescence, young people often experience variations in height and weight. A girl or boy who puts on weight before having a growth spurt in height may look plump, while a student who grows taller but not heavier may appear rather thin. These changes should not necessarily be viewed as signs or symptoms of an eating disorder.

You should be concerned about students who:

• Complain about their bodies or say they are too fat even though they appear to be of normal weight or even rather thin.
• Talk about being on a diet or avoiding nutritious foods because they are "fattening."
• Are overweight and appear sad.
• Are being teased about their weight.
• Are spending more time alone.
• Are obsessed with maintaining low weight to enhance their performance in sports, dance, acting, or modeling.

Students with any of these characteristics may be at an increased risk for developing an eating disorder. You may also want to look for other signs and symptoms of eating disorders, such as those listed [in the following section].

Proof is not necessary - having a concern that something may be wrong is enough to initiate a conversation with the student or a family member. School personnel should look for signs of possible problems and act immediately.

If you are concerned about a student, here's what you can do:

• Recognize that school personnel do not have the skills to deal with the underlying emotional turmoil that often accompanies eating and exercise problems.
• Share information with other staff members who know the student. Find out if they have noticed similar signs.
• Decide together the best course of action and who should talk to the student and family members.

"Middle school personnel are less likely to see students with a fully developed eating disorder, but you may notice students who appear to be rapidly losing or gaining weight. However, it is difficult to ascertain whether weight changes that occur during puberty are normal or are signs of eating disorders."

- Richard Kreipe, MD, Chief, Adolescent Medicine, University of Rochester

TALKING TO A STUDENT OR FAMILY MEMBER Your goal is to communicate to the student that you care and to refer her or him to a health care provider knowledgeable about eating disorders.For more information on how to talk to students and family members, see the information sheet, "How To Help a Student."

When talking with a student or family member, be sure to communicate that you care about her or him. List the specific reasons for your concern and recommend that the student be seen by a health care provider knowledgeable in eating disorders. Say, "let's find out if there is a problem." Remain open to further discussion even if the student and/or her or his family do not wish to take your advice right away.

SIGNS AND SYMPTOMS OF EATING DISORDERSPhysical

• Weight loss or fluctuation in short period of time.
• Abdominal pain.
• Feeling full or "bloated."
• Feeling faint or feeling cold.
• Dry hair or skin, dehydration, blue hands/feet.
• Lanugo hair (fine body hair).

Behavioral

• Dieting or chaotic food intake.
• Pretending to eat, throwing away food.
• Exercising for long periods of time.
• Constantly talking about food.
• Frequent trips to the bathroom.
• Wearing baggy clothes to hide a very thin body.

Emotional

• Complaints about appearance, particularly about being or feeling fat.
• Sadness or comments about feeling worthless.
• Perfectionist attitude.

In your interactions with students, you may notice one or more of the physical, behavioral, and emotional signs and symptoms of eating disorders.

Your school may consider developing a protocol that provides guidelines on talking with students and family members and making referrals to health care providers knowledgeable about eating disorders. It is also useful to have your principal designate an eating disorders resource person who will become acquainted with local resources for referral.

Treatment can save the life of someone with an eating disorder. Friends, relatives, teachers, and health care providers all play an important role in helping an ill person begin and continue treatment. Early detection of an eating disorder is important to increase the likelihood of successful treatment and recovery.

"I got noticed and was complimented on my weight loss at first, but I got carried away. Then, no one said anything, or if they did, it was only 'you're too skinny... eat!' Had someone said sooner that I needed help, I may have lost only 1 year to anorexia, instead of 6."²²

- Jill, Age 22
"Our body shapes are beautifully different. We need to work hard on self-love and feeling good about who we are on the inside. When we don't, food becomes too important." 23
- Victoria Johnson, African American Fitness Professional

Students of all ethnic and cultural groups are vulnerable to developing eating disorders.

It is a common misperception that eating disorders occur only among white upper-class females. However, recent research has confirmed that eating disorders occur in all socioeconomic groups and also among males and ethnically diverse populations. The causes, warning signs and symptoms, and consequences of eating disorders are similar for all students.

One out of every 10 diagnosed cases of eating disorders occurs in males, which means that hundreds of thousands of young men have eating disorders that cause serious health problems.²⁴

Current studies indicate that eating problems do vary by ethnicity, with some of them occurring at higher rates in some populations than others. It appears that among female children, adolescents, and adults, eating disturbances are equally common in Hispanic females, perhaps more frequent among American Indians, and less frequent among blacks and Asian Americans in comparison to whites.²⁵ Because eating disorders may not be suspected in males or girls from ethnically diverse populations, treatment may be delayed until the illness is quite severe.²⁶

Several information sheets in this packet provide more information on how eating disorders affect different ethnic and cultural groups, as well as boys.

Each member of a school community can help create an environment that discourages eating and promotes the early detection of eating disorders.

Why do some students at high risk for health-compromising behaviors successfully navigate adolescence and avoid behaviors that make them vulnerable to poor health and others do not?²⁷

A study reported in the Journal of the American Medical Association (JAMA) found that of all the forces that influence adolescent health-risk behavior, the most critical are the family and school contexts.²⁸ Both a high expectation for student performance and showing concern for a student's welfare communicate a sense of caring that is one of the major protective factors against a variety of risky behaviors.

The protective factors that are considered most amenable for classroom intervention are "coping and life skills," such as problem solving, decision making, assertiveness, communication, and stress management.

Media messages that equate thinness with beauty can contribute to development of negative body images among girls. Training in media literacy can help students analyze media messages and resist those that feature thin and unrealistic body shapes.

Other effective strategies include conducting mentoring programs, changing school policies on harassment, and integrating into existing health and science curriculum information on growth patterns in puberty and the negative consequences of dieting.

All teachers and staff can serve as personal agents of change, both inside and outside the classroom, to help students avoid disordered eating and other associated risk behaviors. They can accomplish this by providing appropriate information and skills as well as by creating an environment that students perceive to becaring and responsive to their needs.

In traditional Fijian culture, round, robust figures have long been the standard for beauty. The introduction of Western television shows seems to be changing this cultural norm. Harvard researchers conducted a study on Fijian girls and found that from 1995, when broadcast television was introduced, indicators of disordered eating, such as high EAT-26 scores and reports of self-induced vomiting, dramatically increased over a period of 3 years. Fifty percent of the girls who watched television on three or more nights a week described themselves as unhappy with the size or shape of their bodies or described themselves as "too fat." These same girls were also more likely to diet than girls who watched less television.²⁹

"When girls in this culture say 'I feel fat,' they are trying to tell us they are struggling with self-esteem and identity. They use the term 'fat' as a symbolic expression for a wide range of thoughts and feelings that include feeling out of control, anxious, fearful and unworthy."³⁰

- Craig Johnson, PhD, Director, Eating Disorders Program, Tulsa, Oklahoma
A March 1999 article in Pediatrics reported on a school-based study that showed discontentment with body weight and shape was directly related to the frequency of reading fashion magazines. Pictures in magazines had a strong impact on girls' perceptions of their weight and shape. Of the 548 5th- through 12th-grade girls, 69 percent reported that magazine images influenced their idea of the perfect body shape, and 47 percent reported wanting to lose weight because of magazine images.³¹

Answering the following questions will give you a snapshot of your school's culture and help you think about how you can integrate ways to discourage disordered eating and promote early detection of eating disorders into your school's ongoing activities.

Do we teach:

• The nature and dangers of dieting?
• Weight and size changes that occur during puberty?
• Genetic effects and diversity of weight and shape?
• Media literacy skills?
• Problem-oriented coping skills?
• Assertive communication skills?
• Listening skills?

Do we discourage:

• Calorie-restrictive dieting?
• Weight- and shape-related teasing?
• Gender stereotyping?
• Sexual harassment?

Are we attentive to students who:

• Express low self-esteem, anxiety, obsessive-compulsiveness, or perfectionism?
• Say they are too fat?
• Are teased about their weight or shape?
• Have a family history of eating disorders, drug abuse, or mental health problems?
• Experience adverse or stressful life events?

"Providing students with positive coping and life skills education may help in discouraging eating disorders as well as drug, alcohol, pregnancy, and delinquency problems. Changes in parental and teacher attitudes are important, as are changes in school policies concerning harassment, teasing, and being weighed in public."
- Linda Smolak, PhD, Professor, Department of Psychology, Kenyon College

Do we promote:

• Role models of all sizes and shapes who are praised for accomplishments and appearance?
• Definitions of beauty that focus on self-respect, assertiveness, and generosity of spirit?
• Pathways to success unrelated to external appearance?

Do we offer:

• Peer support groups?
• Adult mentoring programs?
• Opportunities for teachers, students, parents, and others to discuss school policies regarding teasing, bullying, sexual harassment, and gender role constraints?
• Speakers or in-service programs on eating disorders?
• Parent education on eating disorders and on how nutrition and positive body image affect learning?
• Partnerships in which school personnel work with community organizations?

Does our school:

• Provide teachers with information about the signs and symptoms of eating disorders?
• Have a protocol that provides guidelines on the referral of students to health care providers knowledgeable about eating disorders?
• Have an eating disorders resource person who is acquainted with local and national resources for referral?
• Have a list of resources for school personnel who may want additional information on eating disorders?
• Using the BodyWise Information Packet

The BodyWise information packet includes a set of materials that you can reproduce and distribute to other school personnel, including teachers, coaches, school nurses, counselors, the principal, and other administrators. We suggest that you keep the originals and make copies for members of your school staff and, as needed, for parents and students.

The packet consists of the items listed below.
Information Sheets
Information Sheets for School Personnel

These information sheets provide practical information for teachers, school nurses and counselors, administrators, and physical education teachers, coaches, and dance instructors about disordered eating and eating disorders. Suggestions are provided to enable school personnel to respond effectively to warning signs and help create a positive school culture. The sheets feature quotes and stories that highlight the experiences of students and school personnel. Each sheet concludes with a list of additional available resources.

How To Help a Student

This information sheet provides suggestions on how to approach a student who may have an eating disorder.

How To Help a Friend

Students will often notice the signs of a possible eating disorder before school personnel or parents. This information sheet can be reproduced and given to students who express their concerns about a friend.

Special Student Populations

Information sheets addressing how eating disorders affect boys and ethnically diverse girls are included in the packet to help dispel the myth that eating disorders are only a problem among middle- and upper-income white girls.

Information Sheets for Parents and Other Caregivers

Two information sheets are included for parents. The first provides basic information on eating disorders, how to detect them, and how to discourage disordered eating and support the development of a positive body image. The second, written in Spanish, provides basic information for parents and suggestions on how to seek assistance when concerned about their children. The information sheet also addresses the impact of acculturation and media exposure on Hispanic children's body image and eating behaviors.

Resource Sheets

The BodyWise packet includes resource sheets developed specifically for middle school personnel. The resource sheets list:

• Professional books for school personnel that discuss girls' health issues and eating disorders and offer specific recommendations relevant for school personnel.
• Curricular support materials that teachers may use for planning classroom lessons.
• Young people's reading lists for individual and classroom reading, including both fiction and nonfiction titles.
• Videos on body image, eating disorders, and media literacy that may be used for continuing education for school personnel and shown to middle-school students and family members.
• Educational organizations that provide information on preadolescent health, eating disorders, and media literacy.

"Students learn by what they see and hear. Parents and teachers who model good eating behavior reinforce what they learn in class. Students also need the help of school policy makers who affect their environments. Policy makers can ensure that a choice of healthy menu items exists in the school cafeteria and place limits on the access to unhealthy snacks and beverages in vending machines and from fund raising activities." ³²
- Kweethai Neill, PhD, CHES, Council for Food and Nutrition, American School Health Association

Definitions

Abnormal eating patterns can vary in severity. It is important to distinguish between the terms "eating disorder" and "disordered eating."

An eating disorder is a psychiatric illness with specific criteria that are outlined in the Diagnostic and Statistical Manual (DSM-IV) published by the American Psychiatric Association.

In contrast, disordered eating has not been strictly defined. For the purposes of this handbook, disordered eating may include the following behaviors, particularly when a student also expresses body dissatisfaction, fear of gaining weight, or feeling anxious or stressed:

Skipping meals.

Restricting food choices to a few "acceptable" items.

Focusing excessively on avoiding certain foods, particularly foods that contain fat.

Occasionally bingeing, particularly on snack foods, sweets, and sodas.

Self-induced vomiting, or taking laxatives, diuretics (water pills), or diet pills - to lose weight.
Anorexia Nervosa

Anorexia nervosa is characterized by:³³

Self-induced weight loss or failure to make expected weight gain during periods of growth - resulting in body weight less than 85 percent of that expected.

Intense fear or dread of gaining weight or becoming fat - even though underweight.

Disturbance in one's perception of body weight or shape, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Amenorrhea in females - onset of menses is delayed or arrested (the absence of at least three consecutive menstrual cycles).
There are two subtypes of anorexia nervosa, namely restricting type and binge-eating/purging type. Individuals with the restricting subtype accomplish weight loss primarily through dieting, fasting, or excessive exercise. Individuals with the binge-eating/purging subtype regularly engage in binge eating and purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Some people in this subtype do not binge eat, but do purge after eating small amounts of food.

Bulimia Nervosa

Bulimia nervosa is characterized by:³⁴

Recurrent episodes of binge eating characterized by:
Eating in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most individuals would eat under similar circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior to prevent weight gain. These behaviors are either:
Purging: self-induced vomiting or misuse of laxatives, diuretics (water pills), or enemas.
Nonpurging: fasting or excessive exercise.

Binge eating and inappropriate compensatory behaviors that both occur, on average, at least twice a week for 3 months.

Self-evaluation that is unduly influenced by body shape and weight.
Bulimia nervosa can occur in those with anorexia nervosa or it can occur as a separate condition.

Binge Eating Disorder

Binge eating disorder is characterized by:35

Recurrent episodes of food consumption substantially larger than most people would eat in a similar period of time under similar circumstances.

A feeling of being unable to control what or how much is being eaten.

Binge-eating associated with three (or more) of the following:

• Eating very rapidly.
• Eating until feeling uncomfortably full.
• Eating large amounts of food when not feeling physically hungry.
• Eating alone because of being embarrassed by how much one is eating.
• Feeling disgust, guilt, or depression after overeating.
• Marked distress or unpleasant feelings during and after the binge episode, as well as concerns about the long-term effect of binge eating on body weight and shape.
• Binge-eating that occurs, on average, at least 2 days a week for 6 months.
• Binge eating is frequently experienced by people diagnosed with bulimia nervosa and sometimes experienced by people diagnosed with anorexia nervosa.

However, binge-eating disorder is not associated with the use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).

Overexercising

Overexercising, often practiced by those with anorexia and bulimia, is exercising frequently, intensely, or compulsively for long periods of time in order to control weight. A person who overexercises might display one or more of the following characteristics:

Exercises more frequently and more intensely than is required for good health or competitive excellence.

Gives up time from work, school, and relationships to exercise.

Exercises despite being injured or ill.

Defines self-worth in terms of athletic performance.

Says she or he is never satisfied with a performance or game; does not savor victories.
Overexercising is of particular concern when accompanied by disordered eating, body dissatisfaction, fear of fat, or obsession with weight and food.

End Notes

1 Neumark-Sztainer D, Story M, French SA. Covariations of unhealthy weight loss behaviors and other high-risk behaviors among adolescents. Archives of Pediatric Adolescent Medicine, 1996, vol. 150, no. 3, pp. 304-308; and National Institute of Mental Health. Eating disorders, 1994.

2 The McKnight Foundation. The McKnight Foundation program for research and training in the diagnosis, treatment, and prevention of eating disorders. Minneapolis, MN: Author, 1994, p.9.

3 Arbetter, S. The As and Bs of eating disorders. Current Health, 1994, vol. 21, no. 1, pp. 6-12. Published with permission from Weekly Reader Corporation.

4 Berg, F. Afraid to eat: Children and teens in weight crisis. Hettinger, ND: Healthy Weight Publishing Network, 1997.

5 National Institute of Mental Health, Eating disorders, 1994; and Piran N, Levine MP, Steiner-Adair C (eds.). Preventing eating disorders: A handbook of interventions and special challenges. Philadelphia: Brunner/Mazel, 1999, p. xviii. 6 Ibid.

7 National Institute of Diabetes and Digestive and Kidney Diseases. Binge eating disorder, 1993. Available from NIDDK's Weight-control Information Network (WIN), tel: (877) 946-4627.

8 Arbetter, S. The As and Bs of eating disorders.

9 Harvard Eating Disorders Center Web site www.hedc.org, 1999; and Collins ME. Body figure perceptions and preferences among preadolescent children. International Journal of Eating Disorders, 1991, vol. 10, no. 2, pp. 199-208.

10 Tufts University School of Nutrition Science and Policy. Statement on the link between nutrition and cognitive development in children. Boston: Center on Hunger, Poverty and Nutrition Policy, 1998. The statement may be obtained by calling (617) 627-3956.

11 Ibid.

12 Keys A, et al. The biology of human starvation, vols. 1 and 2. Minneapolis: University of Minnesota Press, 1950 (cited in Reiff & Lampson-Reiff, 1999).

13 Reiff D, Lampson-Reiff KK. Eating disorders: Nutrition therapy in the recovery process. Mercer Island, WA: Life Enterprises, 1999.

14 Ibid.

15 Reiff D, Lampson-Reiff KK. Eating disorders: nutrition therapy in the recovery process, p. 285.

16 Personal conversation with Michael Levine, Ph.D., member of the Office on Women's Health Eating Disorders Steering Committee, June 1999.

17 Brumberg JJ. The body project. New York: Random House, 1997, p. 130.

18 National Institute of Mental Health. Eating disorders, 1994.

19 Nasser M, Katzman M. Eating disorders: Transcultural perspectives inform prevention. In N Piran, MP Levine, C Steiner Adair (eds.), Preventing eating disorders: A handbook of interventions and special challenges. Philadelphia: Brunner/Mazel, 1999, p. 28.

20 National Institute of Child Health and Human Development. Child and adolescent nutrition fact sheet, May 1998.

21 National Institute of Mental Health. Eating disorders, 1994.

22 Personal conversation.

23 Crute S (ed.). Health and healing for African Americans. Emmaus, PA: Rodale Press, 1998.

24 Andersen AE. Eating disorders in males. In KD Brownell, CG Fairburn (eds.). Eating disorders and obesity: A comprehensive handbook. New York: Guilford Press, 1995.

25 Dounchis JZ, Hayden H, Wifley D. Obesity, eating disorders, and body image in ethnically diverse children and adolescents. In JK Thompson, L Smolak (eds.), Body image, eating disorders and obesity in children and adolescents: Theory, assessment, treatment, and prevention. Washington, DC: American Psychological Association, in press.

26 Carlat DJ, Carmargo CA Jr, Herzog DB. Eating disorders in males: A report on 135 patients. American Journal of Psychiatry, 1997, vol. 154, no. 9, pp. 1127-1132; Andersen AE. Eating disorders in males. In KD Brownell, CG Fairburn (eds.), Eating disorders and obesity: A comprehensive handbook. New York: Guilford Press, 1995; and Root MPP. Disordered eating in women of color. Sex Roles, 22(7/8), 525-536, 1990.

27 Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew M, Ireland M, Bearinger LH, & Udry JR. Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health. JAMA, 1997, vol. 278, no. 10, pp.823-32.

28 Ibid.

29 Becker AE, Burwell RA. Acculturation and disordered eating in Fiji. Paper presented at the American Psychiatric Association Annual Meeting, New Research Program Abstracts, 1999; and Becker AE. Body, self, and society: The view From Fiji. Philadelphia: University of Pennsylvania Press, 1995.

30 Personal conversation with Craig Johnson, Ph.D, member of the Office on Women's Health Eating Disorders Steering Committee, July 1999.

31 Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA. Exposure to the mass media and weight concerns among girls. Pediatrics, 1999, vol. 103, no. 3, p. e36.

32 Personal conversation with Kweethai Neill, Ph.D, member of the Office on Women's Health Eating Disorders Steering Committee, May 1999.

33 American Psychiatric Association. Eating disorders. Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV), 1994.

34 Ibid.

35 Ibid.

U.S. Department of Health and Human Services Program Support Center
Office on Women’s Health
Washington, DC: September 1999, 2nd ed. July 2000

Reviewed by athealth January 31, 2014

Tips for Implementing Bullying Prevention Activities

Whether your school plans to implement one or more bullying prevention strategies, or a comprehensive bullying prevention or school improvement initiative, there are several issues to keep in mind that can increase your chances of success. The following are some of the key elements of successful bullying prevention efforts:

Support and Participation of School Leaders

Effective programs require strong leadership and ongoing commitment on the part of school personnel. Before moving forward with an anti-bullying program, be sure to secure administrative support and involvement at both the school and district levels. Depending on the scope of the program, this may mean soliciting funding, release time, and/or support for new policies and curriculum. In addition to the value of their active participation in prevention efforts, teachers and school staff will also be more supportive and effective participants in bullying prevention activities if they know that these activities are fully backed by administrators.

Staff Training and Support

Ongoing staff development and training are critical to the success of your bullying prevention initiative. Set aside time during the school year to share and discuss information about bullying with all school employees. If possible, make an effort to include staff members who are likely to be present in places bullying tends to occur: playground monitors, bus drivers, cafeteria workers, custodial staff, and so forth. Training should include definitions of bullying, indicators of bullying behavior, characteristics of bullies and victims, ways to integrate anti-bullying material into the curriculum, and strategies for addressing bullying behavior. Quality training and opportunities for discussion are essential if all staff are to become supportive and effective participants in your school's anti-bullying activities. According to the Northwest Regional Educational Laboratory:

"Teachers need to understand that their response to bullying makes a difference. Children can't do it alone. You must develop an atmosphere of trust within which kids can have the courage to report bullying, either of themselves or others. If you teach the students to report bullying, but you don't prepare your staff to respond appropriately and effectively, you will be defeating your purpose. Children will quickly learn that they will receive inconsistent or non-responses and will no longer report bullying."

Parent and Community Involvement

Parental and community involvement in the planning and execution of bullying prevention activities is critical to their success. If possible, get parents and other interested citizens involved in both program planning and implementation. Invite them to provide information for program assessments, share survey results with them, offer them training and information about bullying, and keep them abreast of program developments and progress. Furthermore, encourage parents to contact teachers or administrators if they suspect that a child is bullying or being bullied.

Integration Within the Curriculum and Across the K-12 Grade Range

One-shot workshops or a handful of isolated lessons are unlikely to improve bullying problems at school. There are no magic bullets, no quick fixes; true success requires extensive and coordinated efforts. Ideally, such efforts should begin early -- during preschool or kindergarten -- and continue throughout a child's formal education. Bullying prevention activities should, of course, take on different forms according to the developmental stage and sociocultural mix of the students involved. While they will change over the years, it is important to keep in mind that the most effective anti-bullying efforts are ongoing throughout the school year, and are integrated with the curriculum, the school's discipline policies, and other violence prevention efforts at school.

Anti-Bullying Policies

It is crucial to develop and consistently implement a balanced, thoughtfully written policy that is not overresponsive. As mentioned previously, punitive policies such as "zero tolerance" and "three strikes and you're out" policies are not likely to be effective and may even be counterproductive in your school's efforts to combat bullying. According to the Northwestern Regional Educational Laboratory:

"Tougher rules with tougher consequences won't build a positive culture."

Work with parents, students, administrators, teachers, and other school staff to develop a comprehensive, schoolwide policy on bullying that includes a clear definition of bullying and a description of how the school will respond to bullying incidents, as well as a discussion of program philosophy and goals.

Supervision and Intervention

Identify places on school grounds where bullying is more likely to occur, and work with the school staff to ensure that such areas are adequately and consistently supervised. Playgrounds, bus stops, hallways, cafeterias, and school bathrooms often provide easy opportunities for bullies to isolate and assault their victims. The individuals responsible for supervising these areas should be alert and prepared to respond immediately and effectively to any problems that arise.

Skill-Building Among Students

In addition to training school personnel and parents to help prevent and respond appropriately to bullying problems among young people, the students themselves need to learn effective strategies as well. Children need to learn how to avoid or safely defuse potentially aggressive situations, support peers who are or have been involved in such situations, and seek help from adults when necessary. For example, teach students that by simply inviting a student who is standing alone to join their conversation or game, the child will be a less likely target for bullying.

Resources for Bullies, Victims, and Families

Efforts to address bullying behavior are not over when the bully is caught and disciplined. Students who bully repeatedly may benefit from anger management classes or individual counseling, while students who have been victimized may require support in dealing with anxiety and depression. Because many children who bully or are victimized experience bullying at home, it may be necessary to develop intervention strategies involving the whole family. Anti-bullying programs should clearly identify resources for students and families that are available both at school and in the community. Keep in mind, though, that it is important to make sure that your efforts do not result in students being stigmatized, either as bullies or as victims. Placing a label on a student may ensure that he or she gets help, but it may also work to reinforce the bullying dynamic and make it more difficult for students to escape those roles.

Athealth.com 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 highly 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.

Source: Adapted from Exploring the Nature and Prevention of Bullying

Page last modified by Department of Education on January 25, 2010

Page last modified or reviewed by athealth on January 31, 2014

The number of American adults who abuse alcohol or are alcohol dependent is about 17.6 million, or about 8.46% of the adult population (Grant, et al., 2004). Not only is this a primary health concern in itself, but it is additionally of concern because alcohol involvement has significant implications for child well-being and development. Approximately one out of every four U.S. children under the age of 18 years is exposed to the effects of alcohol abuse or dependence in a family member (Grant, 2000).

The field of alcohol treatment began to systematically apply family theories during the mid- to late- 1960s and early 1970s (Zweben & Pearlman, 1983). At that time, family studies began to address the "functions" that alcohol serves in family dynamics, and began to apply a family systems perspective to the understanding of alcohol problems (Berenson, 1976). Another concern involves determining the possible family influences on how individuals develop problems with alcohol-there is consensus that children of alcoholic parents are at a greater risk for developing alcoholism (and other mental or behavioral health problems) than are others, but there is not complete consensus as to the specific mechanisms by which this increased risk is operationalized (Begun & Zweben, 1990). Problems with alcohol (and other substances) have been associated with a number of different family factors, including parental substance use, substance use of siblings, family values and attitudes about substance use, family dynamics and relational patterns, and interaction effects with biological/genetic factors (Waldron & Slesnick, 1998). Family approaches to alcohol treatment have received some research attention, as well (Waldron & Slesnick, 1998).

Critical to a contemporary understanding of alcohol and the family is appreciation for the many diverse forms that families take, and the many different cultural definitions of "family" that apply in the U.S. Early research adopted nuclear family types of definitions involving individuals living together and related to one another through "blood" or legal bonds (e.g., marriage, adoption). Culturally competent social work practice, on the other hand, extends the definition of family membership to include a much wider range of individuals who are linked through various types of formal and informal kinship ties (McGoldrick, Giordano, & Pearce, 1996). American family forms include nuclear, single parent mother, single parent father, ex- and step relations, grandparent/aunt/uncle as parent, foster families, and others. There are tremendous ethnic and cultural differences in family roles, family interdependence and informal support systems, and values about how families interrelate (Fisher & Harrison, 2000).

Family Systems

The family can be conceptualized as a dynamic system that changes over time as membership changes, individuals change and develop, relationships change, and the family's context changes. A family system is interpretable only when its many multiple components are understood-the multiple components include the individual family members, the relationships between them, the family's relationships with its ecological context, the family's history (multigenerational and experience of events), and the host of internal and external forces for developmental change. There are several concepts that are key to a systems perspective on families (Begun, 1996 provides a review):

• The family as a system is more than the sum of its parts. Family systems are composed of interdependent members whose interactions, dynamics, rules, boundaries, and patterns each contribute to family behavior. Individual family members affect the system as a whole, and the system affects individual members-there is a considerable degree of "circularity of influence" involved (Minuchin, 1974).
• Changes in any part of the system affect the entire system. When there are developmental or other changes in an individual family member, changes in the interaction patterns between individuals, new family members are added, or family members leave, the changes reverberate throughout the system.
• Subsystems are embedded throughout the larger family system. Some of the most common subsystems are the couple subsystem, parent-child subsystem, and sibling subsystem; family systems might also include grandparent-grandchild, step-parent and child, half-siblings, ex-partners and other extended family subsystems. Family subsystems do not operate independently of the whole system. Their character and nature are shaped by the overall culture of the family system. Family behavior may be enacted through subsystems rather than the system as a whole. Interactions at the level of the subsystem may impact other family members and subsystems, as well-both directly and indirectly.
• Families exist within a larger social environment context. Families are nested in, are shaped by, and interact with other social systems that affect and are affected by family system processes. Thus, the family system is subject to events that occur within the neighborhood, community, health care, school, workplace, service delivery, societal, economic, historical, and cultural systems. Social workers often rely on eco-maps in order to diagram and assess the nature of a family's complex interactions with its environmental context (Hartman, 1978).
• Families are multigenerational. Family systems are influenced by their histories, as well as by an awareness of their futures. Families may have four or more generations that are currently relevant at one time, and family members are affected by inherited qualities across generations, as well. Social workers often utilize genograms to map the intergenerational and family history influences on family systems (Hartman, 1978).

Another characteristic of family systems approaches is an awareness of the fact that change in family systems is stressful and causes tension in the family. This applies to any change, positive or negative (e.g., death or other loss of a member, marriages, births, adoption, geographic moves, change in social status), because change requires families to dedicate resources and energy to adapt and adjust to their new circumstances.

Family systems are sometimes described by therapists as being very difficult to redirect and resistant to change-once systems have achieved a level of stability or homeostasis, they apply concerted efforts to maintain their hard-earned balance. In fact, warnings have been offered about intervening to change an individual's alcohol abuse without adequately responding to the potentially destabilizing effect of an individual's recovery on the family system-the individual's drinking may represent a family system's homeostatic solution to otherwise distressed relationships (Steinglass, Davis, & Berenson, 1977; Orford, 1975).

The areas and points of family functioning where difficulties are likely to appear during an individual's long-term recovery from alcoholism include:

• Challenges in family role adjustment as the previously alcoholic individual attempts to regain significant roles abandoned through drinking (e.g., involvement in family decision making, authority, sex, intimacy, and other reciprocal exchanges);
• Difficulties in parent-child relationships, especially around behavior management and communication involving adolescent children;
• Developmental changes of family members, family life cycle transition, or situational change events experienced by the family system - e.g., launching children, job loss, adult developmental changes of either partner (Zweben & Perlman, 1983).

In sum, it is vitally important to take into consideration an individual's family (and other social contexts) when exploring the development, maintenance, or treatment of alcohol use disorders. The family system is an important client context, in part because it is one of the interpersonal situations in which the problems occur (Jacob & Leonard, 1988; McCrady & Epstein, 1995). In some cases, the social context of family relationships may be a factor that becomes compelling for the maintenance of the alcohol problems (Shoham, Rohrbaugh, Stickle, & Jacob, 1998)-the specific nature of family interactions may foster the continuation of problematic drinking. In others, this is a context that can facilitate improvement and recovery (Borkovec & Whisman, 1996; Burke, Vassilev, Kantchelov, & Zweben, 2002). Despite the problems related to their substance abuse, individuals with alcohol use disorders typically maintain contact with their parents, brothers and sisters, as well as significant others in their social context, and the family may play an important role in their seeking treatment (Connors, Donovan, & DiClemente, 2001).

Family Influences on the Development of Alcohol Use Disorders

One central finding within the large body of research concerning the etiology of alcohol use disorders is that there exist multiple pathways to these outcomes (Cloninger, Sigvardsson, & Bohman, 1996). Clearly, there are complexly interacting contributions from genetics and other physiological forces, as well as influences from environmental contexts, including family, peer, workplace, neighborhood/community, and media. Alcohol use disorders are multiply determined (Hesselbrock, Hesselbrock, & Epstein, 1999).

Family Genetic Influences

Research indicates that genetic factors may contribute to the development of alcoholism, and family pedigree is the context for this particular source. Family pedigree studies that compare individuals with and without diagnosable alcohol dependency typically show an increase in the lifetime prevalence among biological relatives. The increase in risk for first-degree relatives (brother/sister and parent/child) developing alcohol dependency ranges from four to seven times the risk within the general population (Merikangas, 1990).

Adoption studies have compared children born of an alcoholic parent (usually the father) and reared by nonalcoholic adoptive parents with adopted children born of nonalcoholic parents. In U.S. and Scandinavian studies, the adopted infants of an alcoholic parent developed alcoholism as adults at higher rates than did their counterparts (Cloninger, Bohman, & Sigvardsson, 1981). It is important to note that, while genetic factors are implicated in the development of alcohol use disorders, the findings also indicate that the genetic factors are not deterministic (Kendler, 1995; Slutske, et al., 1998; Cadoret, et al., 1995). In other words, genetic factors interact with other biological and environmental context factors to produce the observed outcomes. Some factors relate to vulnerability and risk, others are protective or resilience factors. Genetics can explain an individual's vulnerability to alcohol use disorders, while environment and other biological factors contribute to their emergence or expression.

In recent years, tremendous progress has been made in uncovering the specific biological mechanisms involved in these observed results. Clearly there is no specific gene or chromosomal "address" that determines who will and who will not develop alcohol use disorders. However, there is increasing evidence concerning the neurotransmitter activity and brain sensitivity that predispose and protect for these disorders. For example, some children of alcoholic parents demonstrate different physiological responses to the effects of alcohol when compared to other individuals. Children of alcoholics may have greater sensitivity to the stress-dampening effects of alcohol than do other individuals (Pihl & Peterson, 1995), as well as less sensitivity to the intoxicating effects of alcohol (Schukit & Smith, 1996). A lack of sensitivity to alcohol's intoxicating effects and increased sensitivity to anxiety-reduction effects of alcohol are associated with greater risk of developing alcohol dependence (Schukit & Smith, 1996), and these features are more apparent among children with alcoholic parent than among individuals with no family history of alcoholism (Molina, Chasin, & Curran, 1994). These physiological mechanisms appear to have a high degree of heritability, at least according to these studies of adult offspring of alcoholic parents.

Family Context Influences

If genetics actually predestined an individual to develop alcohol use disorders, then each alcoholic individual would have first order relatives with the problem, and almost all adopted individuals born of an alcoholic parent would develop the problem-regardless of family rearing environment. Since this is not the case, the genetic factors must interact with other biological and environmental context factors to determine the outcome-both in terms of risk and protective factors. "Individuals reared with an alcohol-abusing parent are at risk for developing alcohol problems due both the genetic factors and to faulty role modeling" (O'Farrell, 1995). Genetics explain an increased vulnerability to alcohol use disorders; family environment contributes to and mediates their emergence or expression (O'Farrell & Fals-Stewart, 1999). For example, alcoholic parents may be more likely to give birth to children with difficult temperaments, which in turn may become a risk factor for substance problems later in life. The impact of temperament on developmental outcomes is not a genetic phenomenon as much as it is a function of a constitutional factor that interacts strongly with social environment contexts (such as parenting environment) to shape an individual's developmental course. Cadoret et al. (1995) reported a higher occurrence of substance abuse among the offspring of alcoholic fathers compared to other individuals, and attributed part of the effect to the increased likelihood of early conduct problems among these offspring.

It is important to note that the very same parenting factors that appear to be linked to adolescent alcohol abuse (e.g., low levels of parental emotional support and a lack of control and monitoring of child behavior) are also linked to a host of other adolescent problem behaviors, such as smoking and early sexual activity (Jacob & Leonard, 1994). Non-substance abusing adolescent children of parents with alcohol use disorders are more likely than others to experience negative emotionality, aggression, stress reaction, alienation, and low well-being (Elkins, McGue, Malone, & Iacono, 2004). Chassin et al. (1996) observed greater emotional reactivity among adolescent children of alcoholic parents than among other adolescents. "Hyperreactivity" to stress may contribute to the emergence of future alcohol use disorders as these individuals attempt to modify their experiences of stress.

Family contexts may provide exposure to key antecedents and consequences for alcohol abuse. For example, many alcohol-abusing individuals cite family arguments, poor family communication, inadequate family problem solving, and nagging at home as antecedents of a drinking episode (O'Farrell & Fals-Stewart, 1999). Family members may also serve to intentionally or inadvertently reinforce or punish the drinking, providing consequences that increase or decrease the likelihood of future drinking episodes.

There also exists research evidence that parenting and other family functioning factors may influence the development of alcohol problems during adolescence or early adulthood. For example, in families with an alcoholic parent, children and adolescents may find that they have easy access to alcohol. It is interesting to note that among preschool aged children, the ability to accurately identify alcoholic beverages simply by smell is directly related to the amount of alcohol consumed by the parents (Noll, Zucker, & Greenberg, 1990). This evidence indicates that an individual's socialization about alcohol begins with the family of origin, and begins at a very young age. Even very young children (aged 3-6 years) begin to formulate expectancies concerning the effects of alcohol, at an age when their primary socialization agents are family members (Zucker, et al., 1995), and expectancies may help to predict later drinking choices (Kushner, et al., 1995). Furthermore, alcoholic parents may present older children and adolescents with a set of norms that tolerate heavy drinking, as well as an absence of parental monitoring for drinking and other potentially harmful behaviors (Dawson, 2000; Rose, 1998; Waldron & Selsnick, 1998).

Alcohol Use Disorder Influences on Family

Drinking and family functioning are linked (Roberts & Linney, 2000), although the relationship may be causal, reciprocal, iterative, or incidental to other causes. There are several family problems that are likely to co-occur with an individual's alcohol abuse, including intimate partner violence, conflict and low relationship satisfaction, economic and legal vulnerability, and child risks. Communication in family systems that involve members with substance problems may be characterized as highly critical, involving considerable amounts of nagging, judgments, blame, complaints, and guilt (Reilly, 1992). Families of individuals with alcohol use disorders are often characterized by conflict, chaos, communication problems, unpredictability, inconsistencies in messages to children, breakdown in rituals and traditional family rules, emotional and physical abuse (Connors, Donovan, & DiClemente, 2001).

Couples

Alcohol problems are common among couples that present for relationship/marital therapy (Halford & Osgarby, 1993), and marital problems are common among those who present for alcohol treatement (O'Farrell & Birchler, 1987). Alcohol abuse affects couples' relationships in a variety of negative ways, including communication problems, increased conflict, nagging, poor sexual relations, and domestic violence (Connors, Donovan, & DiClemente, 2001). Individuals married to persons with alcohol use disorders have higher rates of psychological, stress-related medical problems, and greater use of medical care systems, than other individuals (Connors, Donovan, & DiClemente, 2001; Holder, 1998). There is great controversy over the concept of co-dependency in couples' alcohol-involved relationships. On one hand, there exists some literature describing the characteristics of co-dependency. On the other hand, there are research studies indicating that these characteristics are present in the vast majority of the population (up to 95%), and that there is an absence of evidence supporting the validity of a "diagnosis" of co-dependency (Fisher & Harrison, 2000).

Parent-Child Relations

Parenting functions performed by individuals who are alcohol-impaired may be characterized as inconsistent, unpredictable, and lacking in clear rules and limits (Reilly, 1992). Children of alcoholic parents frequently experience chaotic parenting and poor quality home environments during significant developmental periods (Blanton et al., 1997; Jacob & Leonard, 1994; Zucker et al., 1996). The children of alcoholic parents may be exposed to high levels of family conflict, as well (Moos & Billings, 1982; Webb & Baer, 1995). Parents with a history of substance abuse, compared to other parents, show lower constraint, control, harm avoidance and traditionalism in relation to their families (Elkins, McGue, Malone, & Iacono, 2004). In some cases, disturbances in parent-child relationships are not only exhibited in the dyad involving an alcoholic parent, but also in the dyad involving the other parent. For example, Eiden and Leonard (1996) observed disturbances in the mother-infant attachments among dyads where the father was a heavy drinker.

There is clear documentation of the cognitive impairments associated with chronic, heavy alcohol consumption, and it is important to consider the ways in which these types of impairments might affect the quality and nature of childcare and child rearing (Sher, 1991). There does seem to be an association between parental alcohol/drug related problems and the development of parenting practices in the grown up children. Among mothers, the effect on their parenting appears to be mediated by their own alcohol/drug problems; among fathers, the effect on their parenting appears to result from their own experiences of parental neglect in childhood, leading to a lack of parental warmth and more child neglect (Locke & Newcomb, 2004).

It is important to note that some of the parenting behaviors being described may be a response to behavioral problems among children, not only a cause of developmental problems. Children with difficult temperaments or conduct disorders present challenges that may contribute to poor parenting practices; if parental alcoholism is associated with these traits in offspring, it is not surprising that it is also associated with the observed differences in parenting (Gee & Cadoret, 1996). Also suggestive of this mutual influence model is the observation that interactions between boys and their mothers were more similar than dissimilar among alcoholic and non-alcoholic families, as long as the non-disruptive children were the ones being compared (Dobkin, Charelbois, & Tremblay, 1997).

Children of Alcoholics

"Of an estimated 28 million Americans who are children of alcoholics, nearly 11 million are under the age of 18" (Adger, 2000, p. 235). The risk estimates of children of alcoholics (COAs) developing an alcohol use disorder vary from 4:1 to 9:1 (Russell, 1990). The variability in estimates is attributable to differences in study sampling, definitions and criteria, and assessment strategies. For example, some COAs have a parent who is currently alcoholic, some have been exposed to a parent's alcoholism at some point in their lives, and still others have a parent (or parents) whose alcoholism predated their birth, but it may still have an impact on their development. Another way of looking at these individuals is to identify (1) children of current alcoholics, (2) children of parental period alcoholics, and (3) children of lifetime alcoholics-a parent who was ever an alcoholic (Eigen & Rowden, 2000). The distinction has important implications for epidemiological and assessment purposes.

In essence, children born to and living with a parent experiencing an alcohol use disorder are exposed to both biological and environmental forces that may contribute to developing alcohol problems themselves (Begun & Zweben, 1990). In addition to being at higher risk for developing alcohol problems of their own, children of alcoholics have higher rates of other challenges than do children of non-alcohol impaired parents-even as adults (Holder, 1998). Children of alcoholic parents may have behavioral and school difficulties, including negative self-concepts, fearfulness, loneliness, difficulties in concentrating, attendance, and work completion (Fisher & Harrison, 2000). Some of these difficulties may be attributed to chaotic home environments where basic needs are erratically met (sleep, food, hygiene, supervision). The environments experienced by adolescent sons and daughters of alcoholic parents tend to be characterized by greater stress than those of other adolescents (Chassin et al., 1996). Studies of the Children of Alcoholics Screening Test (CAST) indicate that the scores on this instrument are associated with greater degrees of family dysfunction and disruption, less family cohesion, less family support, inconsistent child care, increased family conflict, and less close/intimate parent-child relationships (Fisher & Harrison, 2000).

It is clear that tremendous heterogeneity exists among the population of children whose parent(s) have alcohol use disorders, although there is currently an incomplete understanding of this heterogeneity. It is not always clear how the developmental outcomes are affected by alcohol per se or by having experienced a stressful childhood environment (e.g., parental disability/mental illness, parents' divorce, parental death). A long-term Danish study of the developmental outcomes for the cohort of children born in 1966 demonstrated that a parent's alcohol abuse during childhood and adolescent years may affect increased mortality, self-destructive behaviors (suicide attempts, drug abuse), experiences of violence requiring hospitalization, teen pregnancy rates, and unemployment among young people in the 15-27 year age range (Christoffersen & Soothill, 2003). The pathway for influence appears to have been the ways in which a parent's alcohol abuse frames childhood experiences with parental violence, family separations, and foster care placements. Similar results were observed in a study of the impact of paternal alcohol abuse on child development outcomes conducted in Norway-the child adjustment difficulties result from an accumulation of risk factors, rather than being a direct effect of the parent's alcohol abuse itself (Haugland, 2003). The relevant risk factors include parental psychological problems, family climate, family health, family conflicts, severity of the alcohol abuse, the child's level of exposure to the alcohol abuse, and distortions or changes in family routines associated with the drinking behavior. It is not clear how these results translate to United States systems.

While it is clear that some risks exist for children growing up exposed to a parent's alcohol abuse, it is also clear that considerable amounts of resiliency also exist. For example, no significant problems are demonstrated by as many as 44% of adult children of alcoholics (D'Andrea, Fisher, & Harrison, 1994). Research suggests that there are multiple determinants of children's degree of vulnerability to adverse events: the nature of the event, the duration of the event, the dosage or intensity of the event, the presence of mitigating or compensatory factors in the environment, intrinsic and acquired resiliencies, interpretations of the events, and resources for coping with the events (Anthony & Cohler, 1987; Begun & Zweben, 1990; Berkowitz & Begun, 2003). Some children who exist within environments that appear to be high in risk for the development of a host of pathological outcomes appear to develop relatively unscathed, while others are harmed-this includes the diversity of children's responses to living with an alcoholic parent (Begun & Zweben, 1990; Werner, 1986; Werner & Smith, 1982).

A child living with an alcoholic parent may also be living with a non-alcoholic parent who may provide many of compensatory parenting functions. A supportive non-alcoholic parent or other caregiving adult (i.e., grandparent, aunt/uncle, elder mentor, adult friend) provides nurturance, protection, and guidance which optimize the development of a child with an alcoholic parent (Werner & Johnson, 2000). Resilient children of an alcoholic parent very often had a non-alcoholic mother/step-mother who served as the "mainstay" of the family-94% of daughters and 80% of sons leading successful adult lives, compared to only 60% and 33.3% respectively of daughters and sons who experienced coping problems. In short, if the child's home environment involved the presence of a functional, central, "buffering" parent, the negative developmental impact of a father's alcoholism was somewhat mitigated; children had more problems when their family lives did not include a person that could be described in this way.

The adolescents living in alcoholic families that are less likely to begin using substances (including alcohol) are those who perceive that they have control over their environment, have good cognitive coping skills, and report that their families are highly organized (Hussong & Chassin, 1997). Young adults from alcoholic families were less likely to report having drinking problems of their own if their families also managed to preserve rituals, structure, and daily routines (Hawkins, 1997). In short, the strength or disruption of the family appears to differentiate between children of alcoholics who experience greater or lesser degrees of well-being as adults, and drinking behavior and family functioning are strongly and reciprocally linked (Roberts & Linney, 2000).

Providing interventions, both preventive and treatment oriented, for children of alcoholics may be difficult and fraught with barriers (Morehouse, 2000). Some examples of barriers include: children (regardless of age) not wanting their parent to know that they are seeking help; children not having transportation or other access issues, including payment resources; fear, anxiety, lack of trust, embarrassment, and other emotional hurdles; parents minimizing the children's need or failing to provide consent; and, programs not being developmentally appropriate or appealing to this age group.

Fetal Alcohol Exposure

One significant source of risk associated with being the child of an alcoholic mother is the possibility of fetal exposure to alcohol or other substances. Fetal exposure to alcohol is associated with heightened probabilities for developmental delays, temperament difficulties, mental retardation, physical deformities, and neurological or other central nervous system vulnerabilities. There is tremendous variability in the expression of these consequences of fetal exposure. The variability is poorly understood and only partially explicable in terms of amounts of alcohol consumed and timing in fetal development when exposure occurs.

Sibling Relationships

Alcohol research first used sibling studies to address the issue of heritability for alcohol problems. In addition to family pedigree and adoption studies, concordance in alcoholism patterns among monozygotic (identical) and dizygotic (fraternal) twin pairs were compared. The results indicate greater concordance (similarity) in the patterns for monozygotic twins than among dizygotic twins and other non-twin sibling pairs, indicating the presence of a genetic influence on the development of alcoholism (Kendler, et al., 1992; McGue, Pickens, & Svikis, 1992). The outcome, however, has a strong environmental influence-otherwise, the concordance among monozygotic twins would be close to 100% (Kendler, 1995).

Brothers and sisters are important environmental influences on many aspects of individual development. They act as agents for socialization-through modeling, delivery of reinforcement/punishment contingencies, reminding one another of rules, and shaping one another's developmental environments. In one study, it was observed that adopted children were significantly more likely to become drinkers if a sibling in their adoptive family consumed alcohol, and this influence was enhanced if the sibling was of the same gender and close in age to the adopted individual (McGue, Sharma, & Benson, 1996).

When an individual is a heavy drinker, that individual's family relationships often are distorted and dysfunctional-this includes relationships with brothers and sisters that may become distressed as a result of a complex of disruptive behaviors that may accompany heavy drinking (Stevenson & Lee, 2001). In some cases, siblings are role models for drug use and may be the ones providing access to substances (Epstein, Botvin, & Diaz, 1999; Epstein, Williams, & Botvin, 2002; Kaufman & Kaufman, 1992; Vakalahi, 2001). Structured support for siblings of adolescent substance abusers may help reduce the risk that they, too, will develop substance problems, as well as reducing other family and social challenges that cause them distress (Boyle, et al., 2001; Gregg & Toumbourou, 2003). On the other hand, siblings, particularly older supportive siblings/step-siblings/foster siblings, are frequently present in the lives of individuals who made good adaptation despite being the son or daughter of an alcoholic parent (Werner & Johnson, 2000).

Families and Recovery

Family members and family process may play a direct role in relapse during recovery, as family conflict and/or strong negative affect (e.g., anger aroused during conflict) may precipitate renewed drinking by abstinent alcoholics (Maisto, O'Farrell, Connors, McKay, & Pelcovits, 1988; Marlatt, 2004, oral presentation). On the other hand, the family may play an important role in facilitating alcohol treatment and recovery processes (Connors, Donovan, & CiClemente, 2001; McCrady, 1986, 1989). The integration of relapse prevention with couples counseling has been shown to be effective (Connors, Donovan, & DiClemente, 2001). Furthermore, family-based therapeutic interventions with adolescent substance abusers are proving more effective than individual or group therapy treatment approaches (Waldron & Slesnick, 1998).

Treatment of a substance abuser appears to have a preventive effect on the mental health and substance abuse risks among their children (O'Farrell & Feehan, 1999). Intervention goals with children of alcoholics are related to reducing their risk for developing alcohol problems of their own through identifying the dysfunctional behaviors that may be predisposing risks and assessing their risk (Fisher & Harrison, 2000). Social workers need to take into consideration the full gamut of vulnerability, risk, resilience, and protective factors expressed in a population in order to understand the heterogeneity in outcomes observed (Begun, 1993).

Family systems models hypothesize a series of homeostatic functions in families that have implications for the processes associated with an individual's recovery from alcohol problems. The underlying assumption is that an individual's maladaptive behavior (e.g., alcohol abuse) reflects dysfunction in the system as a whole (Van Wormer, 1995). As such, the alcohol abuse serves an "adaptive" function for the family system as a whole. For example, the family is allowed to divert its attention away from and to avoid even more threatening issues (e.g., a source of conflict that threatens the system's integrity as a whole) by attending to a member's drinking behavior. In this conceptualization, the drinking behavior transcends the individual and is relational, thus the relationships are a necessary focus of intervention (Waldron & Slesnick, (1998). These types of approaches are designed to address and restructure family interaction patterns that are associated with the alcohol abuse. As a result, the alcohol abuse is no longer "needed" by the family system for its survival.

In addition, some family systems authors have postulated that the family system adopts a host of "adaptive" responses to an individual's alcoholism-emotional repression, emotional walls and barriers, and other survival mechanisms. When the alcoholic family member stops drinking and attempts to re-engage with the family system, the system risks losing its hard-won sense of balance (equilibrium) that was established around the drinking and drinking individual (Brown & Lewis, 1999; Wegscheider, 1981). It is argued that these "adaptive" behaviors may become functionally maladaptive, and that the family system may fight to regain its equilibrium by encouraging a return to drinking or by refusing acceptance of the changed individual who attempts to re-engage or redefine his or her old roles. Interventions based on this model emphasize interactional elements among family members and family structures-redefining roles, explicating rules that direct family behavior, and redefining boundaries (O'Farrell & Fals-Stewart, 1999).

Behavioral Family Models are founded on the principles of social learning theory. The underlying assumption is that alcohol use disorders are acquired and maintained through interactions with the social environment. This includes observational learning (e.g., imitation of role models), operant learning (e.g., behaviors are enhanced or suppressed through reinforcing or punishing consequences), and the presence or absence of opportunities provided by the environment. In this framework, family is important in the development and maintenance of alcohol use disorders for several reasons (McCrady, 1989; Waldron & Slesnick, 1998):
Their behaviors can act as stimulus cues that trigger drinking responses;
Family members act as models for specific alcohol-related behaviors, as well as for more general coping strategies (e.g., observation of drinking to relieve stress).

The family may influence an individual's emotional and physical reactions which are associated with vulnerability to alcohol abuse;
Their responses can act to reinforce or punish efforts at sobriety, abstinence, or reduction of alcohol use
Family members may interfere with the individual experiencing the negative consequences of drinking, and this shielding encourages perpetuation of the drinking.

Models of behavioral family treatment (including Behavioral Marital Therapy, BMT) encourage family members to address the ways in which they can facilitate recovery by providing positively reinforcing responses for behaviors that are incompatible with drinking, removing responses that might be encouraging drinking behavior, and attending to features in the environmental context that encourage drinking. There may be additional components to specific approaches, such as behavioral family therapy to encourage the alcohol abusing family member to enter into treatment or to comply with treatment regimens (e.g., taking medication). BMT addresses the many ways in which an individual's substance abuse affects family process and marital relationships (e.g., communication, conflict, poor sexual relations, violence).

The Family Disease Model suggests that alcohol use disorders are not only diseases affecting an individual, they affect other family members, as well. The model indicates that the disease is manifested in other family members in terms of phenomena such as anxiety, enmeshment and other dysfunctional relationships, low self-esteem, and "co-dependence" (O'Farrell & Fals-Stewart, 1999). Co-dependence, according to this model, is a complementary or parallel disease to alcoholism, exhibited by the alcoholic's significant others. The codependent person presumably exhibits a number of symptoms associated with the disease (e.g., issues about control, perfectionism, "frozen" feelings/emotional blunting, and external referencing), and engages in "enabling" behaviors. Enabling is described as behaviors that perpetuate another person's substance use-for example, protecting the person from experiencing the natural consequences of substance use that might have led to deterrence in the future; making access easier; covering up for the other person's drinking. Treatment approaches formulated around this model do not address the individual's substance use directly, but encourage the significant others to heal themselves from their own disease and recover from the impact that the drinking has had on their lives. The family members are encouraged to detach themselves from the other's drinking, reduce their own emotional distress, and improve their own coping and functioning. There exists little in the way of empirical support for this model (O'Farrell & Fals-Stewart, 1999) that underlies the Al-Anon program.

Readiness to Change within a family system may proceed in a manner that closely parallels the change process for an individual (Connors, Donovan, & DiClemente, 2001). Families that minimize the drinking problem of an individual member are reflecting a process parallel to the individual who is in the precontemplation phase in stages of change concerning an alcohol use disorder. The tendency is to deny that the problem exists, or to acknowledge that drinking is a problem, but to minimize its significance and severity. This precontemplation phase is also generally characterized by a sense of helplessness to change the situation-poor self-efficacy.

As the family becomes increasingly exposed to and aware of the negative consequences associated with the drinking, family members or the family as a whole may shift into the next stage in the process of change: contemplation. Families in this stage evaluate the situation, considering the ways in which the drinking makes the family vulnerable-children and adolescents may be experiencing difficulties with behavior and school, the partner or spouse finds relationship problems with the alcohol abuser to be less and less tolerable. At this point, the family becomes convinced that something must change in the system, but they have not yet made a concrete commitment to specific change actions. In preparation for change, the family has begun to take some small steps toward change of the situation, and has a "near future" timeline for implementing change. This is a point in which the family is likely to be seeking help alternatives and information about treatment options, and may also be considering the pros and cons of other alternatives to life with an alcohol abuser.

One or more of the family members may become increasingly concerned and may begin to explore popular or professional literature, the local phone directories, Internet websites, substance abuse help-lines, as well as consulting friends, clergy, or health care professionals in an attempt to gain information to help them better understand substance use and dependence and to direct them toward possible treatment options. (Thomas et al, 1987, p. 151)

When a family takes specific, notable steps to change the situation, it is said to have entered into the action phase of the change process. Different families settle on different action plans, and a single family may adopt multiple strategies. During this phase of the change process, it is important that action steps be reinforced and supported if change is to proceed. Otherwise, the family may fall back to its earlier ways of thinking, believing, and behaving about the alcohol abuse, in response to the pain, difficulty, and resistance associate with the change process. Thus, whether or not the individual with the alcohol use disorder seeks help, the family system needs support. When the alcohol abuser does seek help, the family needs assistance in seeking and achieving stable, abstinent relationships, and ultimately, in maintaining long-term recovery and relapse prevention.

Empirical Findings

There exists a convincing body of literature indicating that marital and family intervention approaches are more successful in substance abuse treatment than individual intervention alone (O'Farrell, 1992; O'Farrell & Fals-Stewart, 1999; Stanton & Shadish, 1997; Waldron & Slesnick, 1998). More specifically, evidence indicates that there is benefit associated with including focus on an individual's "real world" interpersonal relationships as a fundamental component of intervention efforts (Borovec & Whisman, 1996). Family intervention is associated with better compliance and better treatment outcomes for individuals with alcohol use disorders (McCrady & Epstein, 1996; O'Farrell & Fals-Stewart, 1999). Most recent studies of family intervention approaches involve out-patient treatment (Allen & Litten, 1999).

Family members, as significant others (SOs), play an important role in treatment outcomes. Alcohol treatment outcomes are more significant in situations of positive marital adjustment (Moos, Finney, & Cronkite, 1990). There is little doubt that the significant others in a person's life can actively encourage the individual to maintain problematic behaviors like excessive drinking. However, it is also important to note that involving a "supportive significant other" (SSO) in the process of therapy concerning substance problems is associated with improved retention and more favorable intervention outcomes (Miller & Heather, 1998; Zweben & Pearlman, 1983). O'Farrell (1995) reports that the involvement of spouses or significant others in behavioral couples therapy is associated with improved treatment engagement and reduced drinking behavior compared to individual therapy.

The "significant others" in a person's life can have a great influence on the individual's motivation for change-including a spouse, intimate partner, other family member, or friend (Burke, Vassilev, Kantchelov, & Zweben, 2002; Hasin, 1994). Motivation to change is positively affected by individuals in a person's environment who express concern, offer help, and reinforce the negative consequences of the problem-in a non-demanding way (Miller & Rollnick, 1991). In addition to legal consequences, pressure from family members and significant others is a powerful route to treatment and engagement (Stanton, 1997). Proper involvement of a significant other in the intervention process can help in identifying barriers and solutions, as well as providing corroborating or contrary information about what happens outside of the treatment setting (Burke, Vassilev, Kantchelov, & Zweben, 2002). These individuals can facilitate implementation of change strategies, promote self-efficacy, motivate, help recognize triggers, and act as an "early warning system" for relapse. There is some evidence that these individuals can help improve treatment compliance for alcohol medication regimes, as well, although this evidence is somewhat conflicted when different studies are compared to one another (O'Farrell, 1995).

Project MATCH results (a multi-year, multi-site controlled comparison study of different treatment approaches) indicate an interactive effect on treatment outcomes between the type of intervention modality and social support networks. Twelve-step facilitation (TSP) was found to be more efficacious than Motivational Enhancement Therapy (MET) among clients whose natural social networks supported and reinforced drinking behavior. MET was better than TSP, however, among clients whose social networks were determined to be low support for drinking (Project MATCH, 1997a, 1997b, 1998a). This project also found that individuals, in describing the factor most helpful in maintaining their motivation to change, most often identified spousal support as helping them transition from the action to maintenance stage of recovery (Project Match, 1997a). As noted by Burke, Vassileve, Kantchelov, & Zweben (2002), these findings are consistent with the results of other treatment outcome and natural recovery studies. For example, a relatively short, structured series of family therapy and "significant others" intervention sessions was associated with no difference in drinking outcomes among individuals who have high levels of social support for abstinence, but with distinctly improved outcomes for individuals with low levels of support for abstinence (Longabaugh, Beattie, Noel, Stout, & Malloy, 1993). The addition of a specific couples based Relapse Prevention (RP) training program (CALM-2) at the conclusion of a behavioral marital therapy program is associated with better long-term outcomes than behavioral marital therapy alone (O'Farrell, Choquette, Cutter, Brown, & McCourt, 1993; O'Farrell, 1995)-this is especially true for couples experiencing severe relationship problems.

O'Farrell (1995) summarizes a set of factors that predict acceptance and completion of marital and family therapy by alcoholics. Among the factors are: couple living together, or if separated, are willing to reconcile for the duration of treatment; couple enters treatment following a relationship-threatening crisis; other family members (including the partner) do not have alcoholism; the alcoholic and other family members are without serious psychopathology or other drug abuse; and an absence of family violence that has produced serious injury or is potentially life threatening. These factors are important because in order for treatment to be effective, the alcoholic must be retained in treatment and must participate in the process. McCrady, Epstein, and Hirsch (1999) have demonstrated that alcohol-focused behavioral couples therapy (ABCT) results in greater post-treatment marital happiness, fewer incidents of marital separation, and fewer incidents of domestic violence than general family systems approaches (also see NIAAA's "Alcohol Problems in Intimate Relationships: Identification and Intervention-A Guide for Marriage and Family Therapists," February, 2003).

In situations where both partners in a couple have a similar problem (e.g., both have problems with alcohol), there exists a clear advantage to working with them simultaneously (Allsop & Saunders, 1991). Furthermore, it is important to make control of the alcohol abuse the first priority in working with couples, rather than beginning with the marital relationship, because recurrent alcohol-related incidents and interactions undermine therapeutic relationship gains.

Many of our clients have had previous unsuccessful experiences with therapists who saw the couple in MFT without dealing with the alcohol abuse. The hope that reduction in marital or family distress will lead to improvement in the drinking problem rarely is fulfilled. (O'Farrell, 1995, p. 196).

Once the alcohol issues have come under some degree of control, it is important to begin addressing the family problems caused by drinking (e.g., legal problems, income and financial security issues, housing problems, and issues affecting the family's interactions with the social world), as well as other family issues that may have been overshadowed or obscured by the alcohol problems (O'Farrell, 1995).

In order for a significant other to be supportive of the change process, it may be necessary to address (1) his or her difficulties arising from attempting to cope with the partner's alcohol problems and (2) his or her ambivalence about changing behaviors that contribute to the target individual maintaining the drinking behavior, and (3) means of developing a consensus between the partners about the goals of treatment (Burke et al., 2002). Involvement of the significant other may be counterproductive if this individual is overwhelmed, overly angry and resentful, and/or uncommitted to change (Longabaugh, et al., 1993). Training the significant other may be especially important in situations where the alcoholic is not yet contemplating change and this individual can help move the person into treatment.

The Community Reinforcement Training (CRT) approach is based on an assumption that shifts in the patterns of reinforcement and contingencies can be used to change an alcohol abuser's behavior. The Community Reinforcement and Family Training program (CRAFT) engages family in the process, as well as providing family and supportive significant others with skills for self-protection from intimate partner violence, means of encouraging sobriety, abilities to encourage professional help-seeking, and knowledge of how to support the therapeutic process (Sisson & Azrin, 1986, 1993). In a small sample study, CRT (compared to standard treatment controls) was associated with an average 50% reduction in drinking prior to entering treatment and almost total abstinence during the three months after entering treatment; 6 of 7 alcoholic partners entered treatment compared to none of the 5 control group individuals (whose alcohol consumption did not change during the 3 months period).

In a similar vein, the Unilateral Family Therapy approach (Thomas & Ager, 1993) provides support and attempts to increase the well-being and functioning of individuals engaged in relationships with substance abusers. This approach prepares nonalcoholic partners with their own coping mechanisms, skills to enhance family functioning (e.g., reducing nagging and other forms of negative communication), and ways to facilitate sobriety (including treatment entry) on the part of the alcohol abusing partner. Unilateral Family Therapy (UFT) was associated with significantly greater chances that alcoholics will enter into treatment and/or reduce their drinking in small sample study (Thomas et al., 1987).

A more coercive approach, termed The Johnson Institute Intervention, involves training family and significant others to confront an alcohol abuser, request that he or she seek treatment, and impose consequences for not seeking help. The goal of this program is treatment engagement by the alcohol abuser. The approach is controversial (on practical and ethical bases), and there is limited evidence of effectiveness with the widely diverse population of individuals with alcohol use disorders (Connors, Donovan, & DiClemente, 2001).

Another approach which relies on Al-Anon concepts (i.e., detaching oneself from the other's drinking, accepting that they are powerless to control the alcoholic partner) prepares partners to cope with their own emotional distress and motivations for change, rather than attempting to motivate the alcoholic partner to change (Dittrich, 1993; Dittrich & Traphold, 1984). While it is not clear that the intervention is associated with changes in the drinking individual, there have been persistent improvements in some qualities among the supported partners. And, while there is not a base of controlled research concerning Al-Anon outcomes, there have been studies suggesting that Al-Anon members use fewer ineffective means of coping with the drinking (O'Farrell, 1995).

Controlled, randomized clinical trials are beginning to shape a picture of what is effective in family intervention. One such study compared the CRAFT, Al-Anon, and Johnson Institute Intervention approaches for effectiveness in getting an alcohol abuser into treatment. The highest overall treatment rate for the alcoholic family members was associated with the CRAFT therapy (64%). The vast majority of families in the Johnson Institute condition chose not to complete the intervention; 70% failed to follow-up with the critical confrontation session. Since the Al-Anon facilitation is not designed for engaging the alcoholic in treatment, it is not surprising that this was not a common outcome (Miller, Meyers, & Tonigan, 1999).

The bulk of the controlled clinical research trials that include a family component in alcohol treatment examine adults with partners, and possibly the children of adult alcohol abusers. However, it is also important to consider the role of family and significant others in the treatment of adolescents who struggle with alcohol problems (Brown, Myers, Mott, & Vik, 1994). For example, Integrated Family and Cognitive Behavioral Therapy demonstrated effectiveness on several outcome variables when used with adolescents meeting criteria for alcohol and marijuana use disorders (Latimer, Winters, D'Zurilla & Nichols, 2003). Similarly, Multidimensional Family Therapy resulted in better risk reduction and protection promoting processes than peer group therapy with adolescents referred to treatment for substance abuse and behavioral problems (Liddle, et al., 2004). This type of family based, multi-system, and developmentally oriented intervention targets the functioning of adolescents and their parents across multiple systems and a variety of known risk/protective factors.

It is also important to consider that the most important significant others in an individual's life may not be the most obvious ones-it may not be the spouse, it may be an adult's parent or grandparent, child, or best friend. Not only do these individuals have important contributions to offer in the assessment process, creating an accurate picture of the individual's "relational functions" involving them is often an important aspect of the overall assessment process, as well (Waldron & Slesnick, 1998).

There is evidence that identifies several potential barriers to effective family intervention with substance abuse. The first of these is a potential for violence occurring in the family. Where an acute risk of severe violence exists (violence that may result in serious injury or is life-threatening), the immediate intervention goals must be altered to prioritize safety, safety planning, and conflict containment (O'Farrell & Fals-Stewart, 1999). In these situations, it is recommended to treat the individuals separately (Murphy & O'Farrell, 1996). In some cases there may be legal restrictions in place (i.e., court orders, restraining orders, no contact orders) that preclude conjoint family sessions. A second major barrier is the presence of more than one actively substance abusing family member in the family-particularly if these individuals are partners in consumption. Another demonstrated barrier is the existence of high levels of blame and rumination from family members (usually the partner) toward the substance abusing individual. There may also exist practical barriers to social work intervention from a family perspective-for example, geographical distances; family members who are deceased, divorced, mission, incarcerated or otherwise separated; coordination of family members' schedules and child care responsibilities; securing reimbursement for services delivered to multiple individuals. Finally, social workers should attend to the outcomes emerging from recent large-scale, multi-service, service integration and coordination studies with women on welfare who experience problems with alcohol or other substances, compounded by risks for child protective services involvement and domestic violence (e.g., CASA WORKS for families, or TANF-MATE in Milwaukee, Wisconsin).

References

Adger, H. (2000) Children in alcoholic families: Family dynamics and treatment issues. In S. Abbott (Ed.), Children of Alcoholics, Selected Readings, Volume II, (pp. 235-242). Rockville, MD: National Association of Children of Alcoholics.

Allen, J. P., & Litten, R. Z. (1999) Treatment of drug and alcohol abuse: An overview of major strategies and effectiveness. In B . S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook, (pp. 385-395). NY: Oxford University Press.

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Source: National Institute on Alcohol Abuse and Alcoholism
Adapted from Social Work Curriculum on Alcohol Use Disorders Module 10J
March 2005

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