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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.

Anthony, E. J., & Cohler, B. J. (1987) The invulnerable child. NY: Guilford Press.

Begun, A. (1993) Human behavior and the social environment: The vulnerability, risk, and resilience model. Journal of Social Work Education, 29(1), 26-35.

Begun, A. (1996) Family systems and family-centered care. In P. Rosin, A. D. Whitehead, L. I. Tuchman, G. S. Jesien, A. L. Begun, & L. Irwin, Partnerships in family-centered care: A guide to collaborative early intervention, (pp. 33-63). Baltimore, MD: Paul H. Brookes.

Begun, A., & Zweben, A. (1990). Assessment and treatment implications of adjustment and coping capacities in children living with alcoholic parents. Alcoholism Treatment Quarterly, 7(2), 23-40.

Berenson, D. (1976). Alcohol and the family system. In P. Guerin (Ed.), Family therapy: Theory and practice. NY: Gardner Press.

Berkowitz, M. W., & Begun, A. L. (2003) Designing prevention programs: The developmental perspective. In Z. Sloboda & W. J. Bukoski (Eds.), Handbook of drug abuse prevention: Theory, science, and practice, (pp. 327-350). NY: Kluwer Academic/Plenum Publishers.

Blanton, H., Gibbons, F. X., Gerrard, M., Conger, K. J., & Smith, G. E. (1997). Role of family and peers in the development of prototypes associated with substance use. Journal of Family Psychology, 11(3), 271-288.

Boyle, M. H., Sanford, M., Szatmari, P., Merikangas, K., & Offord, D. R. (2001) Familial influences on substance use by adolescents and young adults. Canadian Journal of Public Health, 92(3), 206-209.

Burke, B. L., Vassilev, G., Kantchelov, A., & Zweben, A. (2002) Motivational interviewing with couples. In W. R. Miller & S. Rollnick (Eds.), Motivational Interviewing: Preparing people for change, 2nd edition (pp. 347-361). NY: Guilford.

Cadoret, R. J., Yates, W. R., Troughton, E., Woodworth, G., & Stewart, M. A. (1995) Adoption study demonstrating two genetic pathways to drug abuse. Archives of General Psychiatry, 52, 42-52.

Chassin, L., Curran, P. S., Hussong, A. M., & Colder, C. R. (1996). The relation of parent alcoholism to adolescent substance use: A longitudinal follow-up study. Journal of Abnormal Psychology, 105(1), 70-80.

Christoffersen, M. N., & Soothill, K. (2003) The long-term consequences of parental alcohol abuse: A cohort study of children in Denmark. Journal of Substance Abuse Treatment, 25(2), 107-116.

Cloninger, C.R., Sigvardsson, S., & Bohman, M. (1996). Type I and Type II alcoholism: An update. Alcohol Health & Research World, 20(1), 18-23.

Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001) Substance abuse treatment and the stages of change: Selecting and planning interventions. NY: Guilford Press.

Dawson, D. A. (2000). The link between family history and early onset alcoholism: Earlier initiation of drinking or more rapid development of dependence? Journal of Studies on Alcoholism, 61(5), 637-646.

D'Andrea, L. M., Fisher, G. L., & Harrison, T. C. (1994) Cluster analysis of children of alcoholics. The International Journal of the Addictions, 29, 565-582.

Dittrich, J. E. (1993) A group program for wives of treatment resistant alcoholics. In T. J. O'Farrell (Ed.), Treating alcohol problems: Marital and family interventions, (pp. 78-114). NY: Guilford Press.

Dobkin, P. L., Charlebois, P., & Tremblay, R. E. (1997) Mother-son interaction in disruptive and nondisruptive adolescent sons of male alcoholics and controls. Journal of Studies on Alcohol, 58(5), 546-553.

Eiden, R. R., & Leonard, K. E. (1996). Parental alcohol use and the mother-infant relationship. Developmental Psychopathology, 8(2), 307-323.

Eigen, L. D., & Rowden, D. W. (2000) A methodology and current estimate of the number of children of alcoholics in the United States. In S. Abbott (Ed.), Children of Alcoholics, Selected Readings, Volume II, (pp. 1-21). Rockville, MD: National Association of Children of Alcoholics.

Elkins, I.J., McGue, M., Malone, S., & Iacono, W. G. (2004) The effect of parental alcohol and drug disorders on adolescent personality. American Journal of Psychiatry, 161(4), 670-676.

Epstein, J. A., Botvin, G. J., & Diaz, T. (1999) Etiology of alcohol use among Hispanic adolescents-Sex-specific effects of social influences to drink and problem behavior. Archives of Pediatrics & Adolescent Medicine, 153(10), 1077-1084.

Epstein, G. L., Williams, C., & Botvin, G. J. (2002) How universal are social influences to drink and problem behaviors for alcohol use? A test comparing urban African-American and Caribbean-American adolescents. Addictive Behaviors, 27(1), 75-86.

Fisher, G. L., & Harrison, T. C. (2000). Substance abuse: Information for school counselors, social workers, therapists, and counselors, 2nd edition. Boston: Allyn & Bacon.

Ge, X., & Cadoret, R. J. (1996) The developmental interface between nature and nurture: A mutual influence model of child antisocial behavior and parent behaviors. Developmental Psychology, 32(4), 574-589.

Geiss, S. K. & O'Leary, K. D. (1981) Therapist ratings of the frequency and severity of marital problems: Implications for research. Journal of Marital and Family Therapy, 7, 515-520.

Grant, B. F. (2000). Estimates of U.S. children exposed to alcohol abuse and dependence in the family. American Journal of Public Health, 90(1), 112-116.

Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, S. P., Dufour, M.C. & Pickering, R. P. (2004). THe 12-month prevalence and trends in DSM-IV alcohol abuse and dependence : United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence, 74, 223-234.

Gregg, M. E., & Toumbourou, J. W. (2003) Sibling peer support group for young people with a sibling using drugs: A pilot study. Journal of Psychoactive Drugs, 35(3), 311-319.

Halford, W. K., & Osgarby, S. M. (1993) Alcohol abuse in clients presenting with marital problems. Journal of Family Psychology, 6, 245-254.

Hartman, A. (1978) Diagrammatic assessment of family relationships. Social Casework, 59(8), 465-476.

Hasin, D. S. (1994) Treatment/self-help for alcohol-related problems: Relationship to social pressure and alcohol dependence. Journal of Studies on Alcohol, 55, 660-666.

Haugland, B. S. M. (2003) Paternal alcohol abuse: Relationship between child adjustment, parental characteristics, and family functioning. Child Psychiatry & Human Development, 34(2), 127-146.

Hawkins, C. A. (1997) Disruption of family rituals as a mediator of the relationship between parental drinking and adult adjustment in offspring. Addictive Behavior, 22(2), 219-231.

Hesselbrock, M. N., Hesselbrock, V. M., & Epstein, E. E. (1999). Theories of etiology of alcohol and other drug use disorders. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook, (pp. 50-72). NY: Oxford University Press.

Holder, H. D. (1998) The cost offsets of alcoholism treatment. In M. Galanter (Ed.), Recent developments in alcoholism, (Vol. 14, pp. 361-374). NY: Plenum Press.

Hussong, A. M., & Chassin, L. (1997) Substance use initiation among adolescent children of alcoholics: Testing protective factors. Journal of Studies on Alcohol, 58(3), 272-279.

Jacob, T., & Leonard, K. (1994). Family and peer influences in the development of adolescent alcohol abuse. In R. A. Zucker, G. M. Boyd, & J. Howard (Eds.), Development of alcohol problems: Exploring the biopsychosocial matrix of risk, (pp.123-155). NIAAA Research Monograph No. 26, NIH Pub. No. 94-3495. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.

Kaufman, E., & Kaufman, P. (1992) Family therapy of drug and alcohol abuse, (pp. 34-45). Boston: Allyn & Bacon.

Latimer, W. W., Winters, K. C., D'Zurilla, T., & Nichols, M. (2003) Integrated family and cognitive-behavioral therapy for adolescent substance abusers: A stage I efficacy study. Drug and Alcohol Dependence, 71(3), 303-317.

Liddle, H. A., Rowe, C. L., Dakof, G. A., Ungaro, R. A., & Henderson, C. E. (2004) Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs, 36(1), 49-63.

Locke, T. F., & Newcomb, M. D. (2004) Child maltreatment, parent alcohol- and drug-related problems, polydrug problems, and parenting practices: A test of gender differences and four theoretical perspectives. Journal of Family Psychology, 18(1), 120-134.

Longabaugh, R., Beattie, M., Noel, N., Stout, R., & Malloy, P. (1993) The effectg of social investment on treatment outcome. Journal of Studies on Alcohol, 54, 465-478.

Maisto, S. A., O'Farrell, T., Connors, G. J., McKay, J., & Pelcovits, M. A. (1988). Alcoholics' attributions of factors affecting their relapse to drinking and reasons for terminating relapse events. Addictive Behaviors, 13, 79-82.

McCrady, B. S. (1986) The family in the change process. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors, (pp. 305-318). NY: Plenum Press.

McCrady, B. S. (1989) Outcomes of family-involved alcoholism treatment. In M. Galanter (Ed.), Recent developments in alcoholism, Volume 7, (pp. 165-182). NY: Plenum Press.

McGoldrick, M., Giordano, J., & Pearce, J. K., Eds. (1996) Ethnicity and family therapy, 2nd edition. NY: Guilford.

McGue, M., Sharma, A., & Benson, P. (1996) Parent and sibling influences on adolescent alcohol use and misuse: Evidence from a U.S. adoption cohort. Journal of Studies on Alcohol, 57(1), 8-18.

Merikangas, K. R. (1990) The genetic epidemiology of alcoholism. Psychological Medicine, 20, 11-22.

Miller, W. R., & Heather, N. (1998) Treating addictive behaviors, 2nd edition. NY: Plenum.

Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999) Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 67, 688-697.

Molina, B. S., Chassin, L., & Curran, P. J. (1994) A comparison of mechanisms underlying substance use for early adolescent children of alcoholics and controls. Journal of Studies in Alcohol, 55(3), 269-276.

Moos, R. H., & Billings, A. G. (1982) Children of alcoholics during the recovery process: Alcoholic and matched control families. Addictive Behavior, 7(2), 155-163.

Moos, R. H., Finney, J. W., & Cronkite, R. C. (1990) Alcoholism treatment: Context, process, and outcome. NY: Oxford University Press.

Morehouse, E. R. (2000) Matching services and the needs of children of alcoholic parents: A spectrum of help. In S. Abbott (Ed.), Children of Alcoholics, Selected Readings, Volume II, (pp. 95-117). Rockville, MD: National Association of Children of Alcoholics.

Noll, R. B., Zucker, R. A., & Greenberg, G. S. (1990) Identification of alcohol by smell among preschoolers: Evidence for early socialization about drugs occurring in the home. Child Development, 61(5), 1520-1527.

O'Farrell, T. J. (1995) Marital and family therapy. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective approaches, 2nd edition, (pp. 195-220). Boston: Allyn and Bacon.

O'Farrell, T. J., & Birchler, G. R. (1987) Marital relationships of alcoholic, conflicted, and nonconflicted couples. Journal of Marital and Family Therapy, 13, 259-274.

O'Farrell, T. J., Choquette, K. A., Butter, H. S. G., Brown, E. D., & McCourt, W. F. (1993) Behavioral marital therapy with and without additional relapse prevention sessions for alcoholics and their wives. Journal of Studies on Alcohol, 54, 652-668.

O'Farrell, T. J., & Fals-Stewart, W. (1999) Treatment models and methods: Family models. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook, (pp. 287-305). NY: Oxford University Press.

O'Farrell, T. J. & Feehan, M. (1999) Alcoholism treatment and the family: Do family and individual treatment for alcoholic adults have preventive effects for children? Journal of Studies on Alcohol, 13, 125-129.

Orford, J. (1975) Alcoholism and marriage: The argument against specialism. Journal of Studies on Alcohol, 36, 1537-1564.

Pihl, R. O., & Peterson, J. B. (1995) Alcoholism: The role of different motivational systems. Journal of Psychiatry & Neuroscience, 20(5), 372-396.

Roberts, L. J., & Linney, K. D. (2000) Alcohol problems and couples: Drinking in an intimate relational context. In K. Schmaling & T. G. Sher (Eds.), The psychology of couples and illness, (pp. 269-310). Washington, DC: American Psychological Association.

Rose, R. J. (1998). A developmental behavior-genetic perspective on alcoholism risk. Alcohol Health & Research World, 22(2), 131-143.

Russell, M. (1990) Prevalence of alcoholism among children of alcoholics. In M. Windle & J. S. Searles (Eds.), Children of alcoholics: Critical perspectives, (pp. 9-38). NY: Guilford Press.

Schukit, M. A., & Smith, T. L. (1996). An 8-year follow-up of 450 sons of alcoholics and control subjects. Archives of General Psychiatry, 53, 202-210.

Sher, K. J. (1991) Children of alcoholics: A critical appraisal of theory and research. Chicago, IL: University of Chicago Press.

Sisson, R. W., & Azrin, N. H. (1993) Family member involvement to initiate and promote treatment of problem drinking. Journal of Behavior Therapy and Experimental Psychiatry, 17, 15-21.

Sisson, R. W., & Azrin, N. H. (1993) Community Reinforcement Training for families : A method to get alcoholics into treatment. In T. J. O'Farrell (Ed.), Treating alcohol problems: Marital and family interventions, (pp. 34-53). NY: Guildford.

Slutske, W. S., Heath, A. C., Dinwiddie, S. H., Madden, P. A., Bucholz, K. K., Dunne, M. P., Statham, D. J., & Martin, N. G. (1998) Common genetic risk factors for conduct disorder and alcohol dependence. Journal of Abnormal Psychology, 107(3), 363-374

Stanton, M. D. (1997) The role of family and significant others in the engagement and retention of drug-dependent individuals. In L. S. Onken, J. D. Blaine, & F. J. Boren, (Eds.), Beyond the therapeutic alliance: Keeping the drug dependent individual in treatment, (pp. 157-180). Rockville, MD: National Institute on Drug Abuse (NIDA).

Steinglass, P. Davis, D.I., & Berenson, D. (1977) Observations of conjointly hospitalized alcoholic couples during sobriety and intoxication. Family Process, 16, 1-16.

Stevenson, G. D., & Lee, M. R. (2001) The negative consequences of heavy drinking and associated disruptive behaviors for sibling relationship performance. Sociological Spectrum, 21(4), 507-532.

Thomas, E. J., & Ager, R. D. (1993) Unilateral family therapy with spouses of uncooperative alcohol abusers. In T. J. O'Farrell (Ed.), Treating alcohol problems: Marital and family interventions, (pp. 3-33). NY: Guilford Press.

Thomas, E. J., Santa, C. A., Bronson, D., Oyserman, D. (1987) Unilateral family therapy with spouses of alcoholics. Journal of Social Services Research, 10, 145-162.

Vakalahi, H. F. (2001) Adolescent substance use and family-based risk and protective factors: A literature review. Journal of Drug Education, 31(1), 29-46.

Van Wormer, K. (1995) Alcoholism treatment: A social work perspective. NY: Wadsworth.

Waldron, H. B., & Slesnick, N. (1998). Treating the family. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors, 2nd edition, (pp. 271-283). NY: Plenum Press.

Webb, J. A., & Baer, P. E. (1995). Influence of family disharmony and parental alcohol use on adolescent social skills, self-efficacy, and alcohol use. Addictive Behavior, 20(1), 127-135.

Wegscheider, S. (1981) Another chance: Hope and health for the alcoholic family. Palo Alto, CA: Science & Behavior Books.

Werner, E. E. (1986). Resilient offspring of alcoholics: A longitudinal study from birth to age 18. Journal of Studies on Alcohol, 47, 34-40.

Werner, E. E., & Johnson, J. L. (2000) The role of caring adults in the lives of children of alcoholics. In S. Abbott (Ed.), Children of Alcoholics, Selected Readings, Volume II, (pp. 119-141). Rockville, MD: National Association of Children of Alcoholics.

Werner, E. E., & Smith, R. S. (1982) Vulnerable but invincible: A longitudinal study of resilient children and youth. NY: McGraw Hill.

Zucker, R. A., Kincaid, S. B., Fitzgerald, H. E., & Bingham, C.R. (1995) Alcohol schema acquisition in preschoolers: Differences between children of alcoholics and children of non-alcoholics. Alcoholism: Clinical & Experimental Research, 19(4), 1011-1017.

Zucker, R. A., Ellis, D. A., Bingham, C. R., & Fitzgerald, H. E. (1996). The development of alcoholic subtypes: Risk variation among alcoholic families during the childhood years. Alcohol Health and Research World, 20(1), 46-54.

Zweben, A. & Pearlman, S. (1983). Evaluating the effectiveness of conjoint treatment of alcohol-complicated marriages: Clinical and methodological issues. Journal of Marital and Family Therapy, 9(1), 61-72.

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

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

Alcohol, Violence, and Aggression

Scientists and nonscientists alike have long recognized a two-way association between alcohol consumption and violent or aggressive behavior (1). Not only may alcohol consumption promote aggressiveness, but victimization may lead to excessive alcohol consumption. Violence may be defined as behavior that intentionally inflicts, or attempts to inflict, physical harm. Violence falls within the broader category of aggression, which also includes behaviors that are threatening, hostile, or damaging in a nonphysical way (2). This Alcohol Alert explores the association between alcohol consumption, violence, and aggression and the role of the brain in regulating these behaviors. Understanding the nature of these associations is essential to breaking the cycle of alcohol misuse and violence.

Extent of the Alcohol-Violence Association

Based on published studies, Roizen (3) summarized the percentages of violent offenders who were drinking at the time of the offense as follows: up to 86 percent of homicide offenders, 37 percent of assault offenders, 60 percent of sexual offenders, up to 57 percent of men and 27 percent of women involved in marital violence, and 13 percent of child abusers. These figures are the upper limits of a wide range of estimates. In a community-based study, Pernanen (4) found that 42 percent of violent crimes reported to the police involved alcohol, although 51 percent of the victims interviewed believed that their assailants had been drinking.

Alcohol-Violence Relationships

Several models have been proposed to explain the complex relationships between violence or aggression and alcohol consumption. To avoid exposing human or animal subjects to potentially serious injury, research results discussed below are largely based on experiments on nonphysical aggression. Other studies involving humans are based on epidemiological surveys or data obtained from archival or official sources.

Alcohol Misuse Preceding Violence

Direct Effects of Alcohol.

Alcohol may encourage aggression or violence by disrupting normal brain function. According to the disinhibition hypothesis, for example, alcohol weakens brain mechanisms that normally restrain impulsive behaviors, including inappropriate aggression (5). By impairing information processing, alcohol can also lead a person to misjudge social cues, thereby overreacting to a perceived threat (6). Simultaneously, a narrowing of attention may lead to an inaccurate assessment of the future risks of acting on an immediate violent impulse (7).

Many researchers have explored the relationship of alcohol to aggression using variations of an experimental approach developed more than 35 years ago (8,9). In a typical example, a subject administers electric shocks or other painful stimuli to an unseen "opponent," ostensibly as part of a competitive task involving learning and reaction time. Unknown to the subject, the reactions of the nonexistent opponent are simulated by a computer. Subjects perform both while sober and after consuming alcohol. In many studies, subjects exhibited increased aggressiveness (e.g., by administering stronger shocks) in proportion to increasing alcohol consumption (10).

These findings suggest that alcohol may facilitate aggressive behavior. However, subjects rarely increased their aggression unless they felt threatened or provoked. Moreover, neither intoxicated nor sober participants administered painful stimuli when nonaggressive means of communication (e.g., a signal lamp) were also available (5,9).

These results are consistent with the real-world observation that intoxication alone does not cause violence (4). The following subsections explore some mechanisms whereby alcohol's direct effects may interact with other factors to influence the expression of aggression.

Social and Cultural Expectancies.

Alcohol consumption may promote aggression because people expect it to (5). For example, research using real and mock alcoholic beverages shows that people who believe they have consumed alcohol begin to act more aggressively, regardless of which beverage they actually consumed (10). Alcohol-related expectancies that promote male aggressiveness, combined with the widespread perception of intoxicated women as sexually receptive and less able to defend themselves, could account for the association between drinking and date rape (11).

In addition, a person who intends to engage in a violent act may drink to bolster his or her courage or in hopes of evading punishment or censure (12,13). The motive of drinking to avoid censure is encouraged by the popular view of intoxication as a "time-out," during which one is not subject to the same rules of conduct as when sober (14,15).

Violence Preceding Alcohol Misuse

Childhood Victimization.

A history of childhood sexual abuse (16) or neglect (17) is more likely among women with alcohol problems than among women without alcohol problems. Widom and colleagues (17) found no relationship between childhood victimization and subsequent alcohol misuse in men. Even children who only witness family violence may learn to imitate the roles of aggressors or victims, setting the stage for alcohol abuse and violence to persist over generations (18). Finally, obstetric complications that damage the nervous system at birth, combined with subsequent parental neglect such as might occur in an alcoholic family, may predispose one to violence, crime, and other behavioral problems by age 18 (19,20).

Violent Lifestyles.

Violence may precede alcohol misuse in offenders as well as victims. For example, violent people may be more likely than nonviolent people to select or encounter social situations and subcultures that encourage heavy drinking (21). In summary, violence may contribute to alcohol consumption, which in turn may perpetuate violence.

Common Causes for Alcohol Misuse and Violence

In many cases, abuse of alcohol and a propensity to violence may stem from a common cause (22). This cause may be a temperamental trait, such as a risk-seeking personality, or a social environment (e.g., delinquent peers or lack of parental supervision) that encourages or contributes to deviant behavior (21).

Another example of a common cause relates to the frequent co-occurrence of antisocial personality disorder (ASPD) and early-onset (i.e., type II) alcoholism (23). ASPD is a psychiatric disorder characterized by a disregard for the rights of others, often manifested as a violent or criminal lifestyle. Type II alcoholism is characterized by high heritability from father to son; early onset of alcoholism (often during adolescence); and antisocial, sometimes violent, behavioral traits (24). Type II alcoholics and persons with ASPD overlap in their tendency to violence and excessive alcohol consumption and may share a genetic basis (23).

Spurious Associations

Spurious associations between alcohol consumption and violence may arise by chance or coincidence, with no direct or common cause. For example, drinking is a common social activity for many adult Americans, especially those most likely to commit violent acts. Therefore, drinking and violence may occur together by chance (5). In addition, violent criminals who drink heavily are more likely than less intoxicated offenders to be caught and consequently are over represented in samples of convicts or arrestees (7). Spurious associations may sometimes be difficult to distinguish from common-cause associations.

Physiology of Violence

Although individual behavior is shaped in part by the environment, it is also influenced by biological factors (e.g., hormones) and ultimately planned and directed by the brain. Individual differences in brain chemistry may explain the observation that excessive alcohol consumption may consistently promote aggression in some persons, but not in others (25). The following subsections highlight some areas of intensive study.

Serotonin

Serotonin, a chemical messenger in the brain, is thought to function as a behavioral inhibitor. Thus, decreased serotonin activity is associated with increased impulsivity and aggressiveness (26) as well as with early-onset alcoholism among men (27).

Researchers have developed an animal model that simulates many of the characteristics of alcoholism in humans. Rhesus macaque monkeys sometimes consume alcohol in sufficient quantities to become intoxicated. Macaques with low serotonin activity consume alcohol at elevated rates (25); these monkeys also demonstrate impaired impulse control, resulting in excessive and inappropriate aggression (25,27). This behavior and brain chemistry closely resemble that of type II alcoholics. Interestingly, among both macaques and humans, parental neglect leads to early-onset aggression and excessive alcohol consumption in the offspring, again correlated with decreased serotonin activity (27).

Although data are inconclusive, the alcohol-violence link may be mediated by chemical messengers in addition to serotonin, such as dopamine and norepinephrine (28). There is also considerable overlap among nerve cell pathways in the brain that regulate aspects of aggression (29), sexual behavior, and alcohol consumption (30). These observations suggest a biological basis for the frequent co-occurrence of alcohol intoxication and sexual violence.

Testosterone

The steroid hormone testosterone is responsible for the development of male primary and secondary sexual characteristics. High testosterone concentrations in criminals have been associated with violence, suspiciousness, and hostility (31,32). In animal experiments, alcohol administration increased aggressive behavior in socially dominant squirrel monkeys, who already exhibited high levels of aggression and testosterone (33). Alcohol did not, however, increase aggression in subordinate monkeys, which exhibited low levels of aggression and testosterone (6).

These findings may shed some light on the life cycle of violence in humans. In humans, violence occurs largely among adolescent and young adult males, who tend to have high levels of testosterone compared with the general population. Young men who exhibit antisocial behaviors often "burn out" with age, becoming less aggressive when they reach their forties (34). By that age, testosterone concentrations are decreasing, while serotonin concentrations are increasing, both factors that tend to restrain violent behavior (35).

Conclusion

No one model can account for all individuals or types of violence. Alcohol apparently may increase the risk of violent behavior only for certain individuals or sub-populations and only under some situations and social/cultural influences (4,36).

Although much remains to be learned, research suggests that some violent behavior may be amenable to treatment and some may be preventable. One study found decreased levels of marital violence in couples who completed behavioral marital therapy for alcoholism and remained sober during followup (37). Results of another study (7) suggest that a 10-percent increase in the beer tax could reduce murder by 0.3 percent, rape by 1.32 percent, and robbery by 0.9 percent. Although these results are modest, they indicate a direction for future research. In addition, preliminary experiments have identified medications that have the potential to reduce violent behavior. Such medications include certain anticonvulsants (e.g., carbamazepine) (38); mood stabilizers (e.g., lithium) (39); and antidepressants, especially those that increase serotonin activity (e.g., fluoxetine) (40,41). However, these studies either did not differentiate alcoholic from nonalcoholic subjects or excluded alcoholics from participation.

References

(1)Reiss, A.J., Jr., & Roth, J.A., eds. Understanding and Preventing Violence. Vol. 3. Washington, DC: National Academy Press, 1994.

(2)Moss, H.B., & Tarter, R.E. Substance abuse, aggression, and violence. Am J Addict 2(2):149-160, 1993.

(3)Roizen, J. Epidemiological issues in alcohol-related violence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 7-40.

(4)Pernanen, K. Alcohol in Human Violence. New York: Guilford Press, 1991.

(5)Gustafson, R. Alcohol and aggression. J Offender Rehabil 21(3/4):41-80, 1994.

(6)Miczek, K.A., et al. Alcohol, GABAA-benzodiazepine receptor complex, and aggression. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 139-171.

(7)Cook, P.J., & Moore, M.J. Economic perspectives on reducing alcohol-related violence. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 193-212.

(8)Buss, A.H. The Psychology of Aggression. New York: Wiley, 1961.

(9)Gustafson, R. What do experimental paradigms tell us about alcohol-related aggressive responding? J Stud Alcohol 11(suppl):20-29, 1993.

(10)Bushman, B.J. Effects of alcohol on human aggression: Validity of proposed explanations. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 227-243.

(11)Lang, A.R. Alcohol-related violence: Psychological perspectives. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 121-148.

(12)Collins, J.J. Alcohol and interpersonal violence: Less than meets the eye. In: Wolfgang, M.E., eds. Pathways to Criminal Violence. Newbury Park, CA: Sage Publications, 1989. pp. 49-67.

(13)Fagan, J. Intoxication and aggression. In: Tonry, M., & Wilson, J.Q., eds. Crime and Justice. Vol. 13. Chicago: Univ. of Chicago Press, 1990. pp. 241-320.

(14)MacAndrew, C., & Edgerton, R.B. Drunken Comportment. Chicago: Aldine Publishing, 1969.

(15)Zack, M., & Vogel-Sprott, M. Drunk or sober? Learned conformity to a behavioral standard. J Stud Alcohol 58(5):495-501, 1997.

(16)Miller, B.A. Investigating links between childhood victimization and alcohol problems. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 315-323.

(17)Widom, C.S., et al. Alcohol abuse in abused and neglected children followed-up: Are they at increased risk? J Stud Alcohol 56(2):207-217, 1995.

(18)Brookoff, D., et al. Characteristics of participants in domestic violence: Assessment at the scene of domestic assault. JAMA 277(17):1369-1373, 1997.

(19)Raine, A., et al. Birth complications combined with early maternal rejection at age 1 year predispose to violent crime at age 18 years. Arch Gen Psychiatry 51(12):984-988, 1994.

(20)Raine, A., et al. High rates of violence, crime, academic problems, and behavioral problems in males with both early neuromotor deficits and unstable family environments. Arch Gen Psychiatry 53(6):544-549, 1996.

(21)White, H.R. Longitudinal perspective on alcohol use and aggression during adolescence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 81-103.

(22)Jessor, R., & Jessor, S.L. Problem Behavior and Psychosocial Development. New York: Academic Press, 1977.

(23)Virkkunen, M., et al. Serotonin in alcoholic violent offenders. Ciba Foundation Symposium 194:168-182, 1995.

(24)Cloninger, C.R., et al. Inheritance of alcohol abuse: Cross-fostering analysis of adopted men. Arch Gen Ps ychiatry 38:861-868, 1981.

(25)Higley, J.D., et al. A nonhuman primate model of type II excessive alcohol consumption? Part 1. Low cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations and diminished social competence correlate with excessive alcohol consumption. Alcohol Clin Exp Res 20(4):629-642, 1996.

(26)Virkkunen, M., & Linnoila, M. Serotonin and glucose metabolism in impulsively violent alcoholic offenders. In: Stoff, D.M., & Cairns, R.B., eds. Aggression and Violence. Mahwah, NJ: Lawrence Erlbaum, 1996. pp. 87-100.

(27)Higley, J.D., & Linnoila, M. A nonhuman primate model of excessive alcohol intake: Personality and neurobiological parallels of type I- and type II-like alcoholism. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 192-219.

(28)Coccaro, E.F., & Kavoussi, R.J. Neurotransmitter correlates of impulsive aggression. In: Stoff, D.M., & Cairns, R.B., eds. Aggression and Violence. Mahwah, NJ: Lawrence Erlbaum, 1996. pp. 67-86.

(29)Alexander, G., et al. Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annu Rev Neurosci 9:357-381, 1986.

(30)Modell, J.G., et al. Basal ganglia/limbic striatal and thalamocortical involvement in craving and loss of control in alcoholism. J Neuropsychiatry Clin Neurosci 2(2):123-144, 1990.

(31)Dabbs, J.M., Jr., et al. Salivary testosterone and cortisol among late adolescent male offenders. J Abnorm Child Psychol 19(4):469-478, 1991.

(32)Virkkunen, M., et al. CSF biochemistries, glucose metabolism, and diurnal activity rhythms in alcoholic, violent offenders, fire setters, and healthy volunteers. Arch Gen Psychiatry 51:20-27, 1994.

(33)Miczek, K.A., et al. Alcohol, drugs of abuse, aggression, and violence. In: Reiss, A.J., & Roth, J.A., eds. Understanding and Preventing Violence. Vol. 3. Washington, DC: National Academy Press, 1994. pp. 377-570.

(34)Robins, L.N. Deviant Children Grown Up. Baltimore: Williams & Wilkins, 1996.

(35)Brown, G.L., & Linnoila, M.I. CSF serotonin metabolite (5-HIAA) studies in depression, impulsivity, and violence. J Clin Psychiatry 51(4)(suppl):31-43, 1990.

(36)Lipsey, M.W., et al. Is there a causal relationship between alcohol use and violence? A synthesis of evidence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 245-282.

(37)O'Farrell, T.J., & Murphy, C.M. Marital violence before and after alcoholism treatment. J Consult Clin Psychol 63:256-262, 1995.

(38)Gardner, D.L., & Cowdry, R.W. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psychiatry 143(4):519-522, 1986.

(39)Sheard, M.H., et al. The effect of lithium on impulsive behavior in man. Am J Psychiatry 133:1409-1413, 1976.

(40)Coccaro, E.F., et al. Fluoxetine treatment of compulsive aggression in DSM-III-R personality disorder patients. J Clin Psychopharm 10:373-375, 1990.

(41)Salzman, C., et al. Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. J Clin Psychopharm 15(1):23-19, 1995.

National Institute on Alcohol Abuse and Alcoholism
Alcohol Alert No. 38, Updated October 2000

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

What are alternative approaches to mental health care?

An alternative approach to mental health care is one that emphasizes the interrelationship between mind, body, and spirit. Although some alternative approaches have a long history, many remain controversial. The National Center for Complementary and Alternative Medicine at the National Institutes of Health was created in 1992 to help evaluate alternative methods of treatment and to integrate those that are effective into mainstream health care practice. It is crucial, however, to consult with your health care providers about the approaches you are using to achieve mental wellness.

Self-help

Many people with mental illnesses find that self-help groups are an invaluable resource for recovery and for empowerment. Self-help generally refers to groups or meetings that:

• Involve people who have similar needs
• Are facilitated by a consumer, survivor, or other layperson;
• Assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident, addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative;
• Are operated on an informal, free-of-charge, and nonprofit basis;
• Provide support and education; and
• Are voluntary, anonymous, and confidential.

Diet and Nutrition

Adjusting both diet and nutrition may help some people with mental illnesses manage their symptoms and promote recovery. For example, research suggests that eliminating milk and wheat products can reduce the severity of symptoms for some people who have schizophrenia and some children with autism. Similarly, some holistic/natural physicians use herbal treatments, B-complex vitamins, riboflavin, magnesium, and thiamine to treat anxiety, autism, depression, drug-induced psychoses, and hyperactivity.

Pastoral Counseling

Some people prefer to seek help for mental health problems from their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community. Counselors working within traditional faith communities increasingly are recognizing the need to incorporate psychotherapy and/or medication, along with prayer and spirituality, to effectively help some people with mental disorders.

Animal Assisted Therapies

Working with an animal (or animals) under the guidance of a health care professional may benefit some people with mental illness by facilitating positive changes, such as increased empathy and enhanced socialization skills. Animals can be used as part of group therapy programs to encourage communication and increase the ability to focus. Developing self-esteem and reducing loneliness and anxiety are just some potential benefits of individual-animal therapy (Delta Society, 2002).

Expressive Therapies

Art Therapy: Drawing, painting, and sculpting help many people to reconcile inner conflicts, release deeply repressed emotions, and foster self-awareness, as well as personal growth. Some mental health providers use art therapy as both a diagnostic tool and as a way to help treat disorders such as depression, abuse-related trauma, and schizophrenia. You may be able to find a therapist in your area who has received special training and certification in art therapy.

Dance/Movement Therapy: Some people find that their spirits soar when they let their feet fly. Others-particularly those who prefer more structure or who feel they have "two left feet"-gain the same sense of release and inner peace from the Eastern martial arts, such as Aikido and Tai Chi. Those who are recovering from physical, sexual, or emotional abuse may find these techniques especially helpful for gaining a sense of ease with their own bodies. The underlying premise to dance/movement therapy is that it can help a person integrate the emotional, physical, and cognitive facets of "self."

Music/Sound Therapy: It is no coincidence that many people turn on soothing music to relax or snazzy tunes to help feel upbeat. Research suggests that music stimulates the body's natural "feel good" chemicals (opiates and endorphins). This stimulation results in improved blood flow, blood pressure, pulse rate, breathing, and posture changes. Music or sound therapy has been used to treat disorders such as stress, grief, depression, schizophrenia, and autism in children, and to diagnose mental health needs.

Culturally Based Healing Arts

Traditional Oriental medicine (such as acupuncture, shiatsu, and reiki), Indian systems of health care (such as Ayurveda and yoga), and Native American healing practices (such as the Sweat Lodge and Talking Circles) all incorporate the beliefs that:

• Wellness is a state of balance between the spiritual, physical, and mental/emotional "selves."
• An imbalance of forces within the body is the cause of illness.
• Herbal/natural remedies, combined with sound nutrition, exercise, and meditation/prayer, will correct this imbalance.

Acupuncture: The Chinese practice of inserting needles into the body at specific points manipulates the body's flow of energy to balance the endocrine system. This manipulation regulates functions such as heart rate, body temperature, and respiration, as well as sleep patterns and emotional changes. Acupuncture has been used in clinics to assist people with substance abuse disorders through detoxification; to relieve stress and anxiety; to treat attention deficit and hyperactivity disorder in children; to reduce symptoms of depression; and to help people with physical ailments.

Ayurveda: Ayurvedic medicine is described as "knowledge of how to live." It incorporates an individualized regimen - such as diet, meditation, herbal preparations, or other techniques - to treat a variety of conditions, including depression, to facilitate lifestyle changes, and to teach people how to release stress and tension through yoga or transcendental meditation.

Yoga/meditation: Practitioners of this ancient Indian system of health care use breathing exercises, posture, stretches, and meditation to balance the body's energy centers. Yoga is used in combination with other treatment for depression, anxiety, and stress-related disorders.

Native American traditional practices: Ceremonial dances, chants, and cleansing rituals are part of Indian Health Service programs to heal depression, stress, trauma (including those related to physical and sexual abuse), and substance abuse.

Cuentos: Based on folktales, this form of therapy originated in Puerto Rico. The stories used contain healing themes and models of behavior such as self-transformation and endurance through adversity. Cuentos is used primarily to help Hispanic children recover from depression and other mental health problems related to leaving one's homeland and living in a foreign culture.

Relaxation and Stress Reduction Techniques

Biofeedback: Learning to control muscle tension and "involuntary" body functioning, such as heart rate and skin temperature, can be a path to mastering one's fears. It is used in combination with, or as an alternative to, medication to treat disorders such as anxiety, panic, and phobias. For example, a person can learn to "retrain" his or her breathing habits in stressful situations to induce relaxation and decrease hyperventilation. Some preliminary research indicates it may offer an additional tool for treating schizophrenia and depression.

Guided Imagery or Visualization: This process involves going into a state of deep relaxation and creating a mental image of recovery and wellness. Physicians, nurses, and mental health providers occasionally use this approach to treat alcohol and drug addictions, depression, panic disorders, phobias, and stress.

Massage therapy: The underlying principle of this approach is that rubbing, kneading, brushing, and tapping a person's muscles can help release tension and pent emotions. It has been used to treat trauma-related depression and stress. A highly unregulated industry, certification for massage therapy varies widely from State to State. Some States have strict guidelines, while others have none.

Technology-Based Applications

The boom in electronic tools at home and in the office makes access to mental health information just a telephone call or a "mouse click" away. Technology is also making treatment more widely available in once-isolated areas.

Telemedicine: Plugging into video and computer technology is a relatively new innovation in health care. It allows both consumers and providers in remote or rural areas to gain access to mental health or specialty expertise. Telemedicine can enable consulting providers to speak to and observe patients directly. It also can be used in education and training programs for generalist clinicians.

Telephone counseling: Active listening skills are a hallmark of telephone counselors. These also provide information and referral to interested callers. For many people telephone counseling often is a first step to receiving in-depth mental health care. Research shows that such counseling from specially trained mental health providers reaches many people who otherwise might not get the help they need. Before calling, be sure to check the telephone number for service fees; a 900 area code means you will be billed for the call, an 800 or 888 area code means the call is toll-free.

Electronic communications: Technologies such as the Internet, bulletin boards, and electronic mail lists provide access directly to consumers and the public on a wide range of information. On-line consumer groups can exchange information, experiences, and views on mental health, treatment systems, alternative medicine, and other related topics.

Radio psychiatry: Another relative newcomer to therapy, radio psychiatry was first introduced in the United States in 1976. Radio psychiatrists and psychologists provide advice, information, and referrals in response to a variety of mental health questions from callers. The American Psychiatric Association and the American Psychological Association have issued ethical guidelines for the role of psychiatrists and psychologists on radio shows.

This fact sheet does not cover every alternative approach to mental health. A range of other alternative approaches - psychodrama, hypnotherapy, recreational, and Outward Bound-type nature programs - offer opportunities to explore mental wellness. Before jumping into any alternative therapy, learn as much as you can about it. In addition to talking with your health care practitioner, you may want to visit your local library, book store, health food store, or holistic health care clinic for more information. Also, before receiving services, check to be sure the provider is properly certified by an appropriate accrediting agency.

Note: Inclusion of an alternative approach or resource in this fact sheet does not imply endorsement by the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.
SAMHSA'S National Mental Health Information Center
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Anger. Everybody experiences it and everybody expresses it. It is a natural and healthy human emotion when managed effectively. But it can be a source of various physical, mental, emotional, social, or legal problems when not managed effectively. It is often a problem in one of these areas that brings a client in for counseling, either on a voluntary or a mandated basis. As a counselor, there are numerous and varied options for intervention. And there are numerous and varied aspects to consider before selecting an appropriate intervention.

Defining Anger

There are many different views from which to consider the construct of anger. Dahlen and Deffenbacher (2001) identify three main ingredients to anger. First, there is an anger-eliciting stimulus, typically an easily-identifiable external source (e.g., somebody did something to me) or internal source (e.g., emotional wounds). Second, there is a pre-anger state, which includes one's cognitive, emotional, and physical state at the time of provocation; one's enduring psychological characteristics; and one's cultural messages about anger and about expressing anger. Third, there is one's appraisal of the anger-eliciting stimulus and one's ability to cope with the stimulus. All three of these ingredients interact to create a state of being angry.

Dahlen and Deffenbacher (2001) also identify four related domains in which anger exists. First, in the emotional and experiential domain, anger is a feeling state ranging in intensity from mild annoyance to rage and fury. Second, in the physiological domain, anger is associated with adrenal release, increased muscle tension, and activation of the sympathetic nervous system.

Third, in the cognitive domain, anger is associated with biased information processing. Fourth, in the behavior domain, anger can be either functional (e.g., being assertive, setting limits) or dysfunctional (e.g., being aggressive, withdrawing, using alcohol and drugs, etc.).

Rhoades (n.d.) provides additional ways to understand anger. What is the source and expression of the anger? Is it intense and situation-specific or chronic and generalized? What is the extent of the anger? Does it easily and quickly evolve into deep feelings of resentment? Is it coupled with intense aggression or explosiveness? Has it become uncontrollable? What is the anger hiding? Is it a cover-up for fear, being used as a shield to keep other people at a distance so they are unable to see one's insecurities and weaknesses?

Expressing Anger

The expression of anger can take many forms. Some common means of expressing anger include venting, resisting, seeking revenge, expressing dislike, avoiding the source of anger, and seeking help (Marion, 1997). However, in many cultures, people are taught that while expressing anxiety, depression or other emotions is acceptable, expressing anger is not (Controlling anger before it controls you, n.d.). As a result, many people never learn how to handle their own or others' anger effectively or to channel it constructively.

Gorkin (2000) distinguishes between the intention and the usefulness of anger expressions. In terms of intention, the expression of anger can be purposeful or spontaneous. The purposeful expression of anger is intentional, has a significant degree of consideration or calculation, and yields a high degree of self-control. The spontaneous expression of anger is immediate, has little premeditation, and yields little to moderate self-control.

In terms of usefulness, the expression of anger can be constructive or destructive. Constructive expression of anger affirms and acknowledges one's integrity and boundaries without intention to threaten another person. Destructive expression of anger defensively projects and rigidly fortifies one's vulnerable identity and boundaries. These distinctions provide for four basic expressions of anger. Purposeful and constructive expression leads to assertion. Purposeful and destructive expression leads to hostility. Spontaneous and constructive expression leads to passion and suffering. And spontaneous and destructive expression leads to rage, violence, screaming, and hitting. With respect to rage, one can be outraged, by a seemingly clear and external (sometimes criminal) target, or one can be "in-raged" (Gorkin, 2000), by a reaction to still unresolved internal hurts and humiliations (vs. actual, immediate stimulus-and-response provocation).

Although much of the work in anger management focuses on helping people understand what triggers their anger and on learning a healthier response, or expression, of that anger, the debate continues regarding the healthiest ways to express anger. Interestingly, some sources (e.g., Schwartz, 1990) indicate that repressing anger can be adaptive for coping with certain emotions. Other sources (e.g., Controlling anger before it controls you, n.d.) document that suppressing anger can lead to headaches, hypertension, high blood pressure, depression, emotional disturbances, gastrointestinal disorders, respiratory disorders, skin disorders, genitourinary disorders, arthritis, disabilities of the nervous system, circulatory disorders, and even suicide. It is important to learn to identify whether or not a client's reactions to and expressions of anger are a problem.

Assessing Anger

How does a client know when his or her anger is more of a problem than a help? Few formal assessments exist to quantifiably measure the level of one's anger. However, there are numerous qualitative indicators to review with clients to understand the extent of their concerns about their anger and anger management strategies.

• Is the anger chronic, long-lasting, too intense, or too frequent (Rhoades, n.d.)?
• Does the anger disrupt the client's thinking, affect the client's relationships (Rhoades, n.d.), or affect the client's school or work performance?
• Does the client exhibit frequent loss of temper at slight provocations, passive-aggressive behavior, a cynical or hostile personality, chronic irritability and grumpiness?
• Has the client begun to display low self-esteem, sulking, or brooding?
• Is the client withdrawing socially from family and friends?
• Is the client getting physically sick or doing damage to one's own or others' bodies or property?
• Is the client experiencing physical symptoms such as increased heart rate, increased blood pressure, or increased adrenaline flow (Controlling anger before it controls you, n.d.)?

Although some of these symptoms may be indicative of other issues, they are also often related to unresolved anger. The bottom line is that when a person becomes a victim to his or her anger, the anger is a problem.

Managing Anger

According to Wellness Reproductions (1991), there are three main methods of dealing with anger. First, there is "stuffing" one's anger, a process in which a person may or may not admit his or her anger to self or others and in which one avoids direct confrontations. A person may stuff his or her anger out of fear of hurting someone, fear of rejection, fear of damaging relationships or fear of losing control. Often, a person who stuffs anger is unable to cope with strong, intense emotions and thinks that anger is inappropriate or unacceptable. Stuffing one's anger typically results in impaired relationships and compromised physical and mental health.

Second, there is escalating one's anger, a process in which a person provokes blame and shame. The purpose is to demonstrate power and strength while avoiding the expression of underlying emotions. A person who escalates his or her anger is often afraid of getting close to other people and lacks effective communication skills. Escalating one's anger typically yields short-term results, impaired relationships, and compromised physical and mental health. Sometimes, escalating one's anger also leads to physical destruction of property or to abusive situations, thus adding the potential for legal ramifications.

Third, there is managing one's anger, a process in which a person is open, honest, and direct and in which one mobilizes oneself in a positive direction. The focus is on the specific behavior that triggered the anger and on the present (past issues are not brought into the current issue). A person who manages his or her anger avoids black and white thinking (e.g., never, always, etc.), uses effective communication skills to share feelings and needs, checks for possible compromises, and assesses what is at stake by choosing to stay angry versus dealing with the anger. Managing one's anger results in an increased energy level, effective communication skills, strengthened relationships, improved physical and mental health, and boosted self-esteem.

Summary

It is this process of managing one's anger that is the primary goal of counseling people to effectively deal with anger. The goal is not to eliminate anger. Anger is a natural and healthy emotion. After a client acknowledges he or she is angry, a counselor can help the client learn how to reduce the emotional and physiological arousal that anger causes and learn to control its effects on people and the environment. To be more effective, practitioners should attempt to understand the extent and expression of the anger, the specific problems resulting from the anger, the function the anger serves, the underlying source of the anger, and the domain the problems occur in (e.g. emotional, physiological, or cognitive) before choosing interventions for the client.

Specific strategies and skills as well as some additional considerations in helping clients manage anger are reviewed in Anger Management 2: Counseling Strategies and Skills.

References

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J.

V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Gorkin, M. (2000, August 17). The four faces of anger. Retrieved July 23, 2003

Marion, M. (1997). Guiding young children's understanding and management of anger. Young Children, 52(7), p. 62-67.

Rhoades, G. F. (n.d.) Anger management online conference transcript. Retrieved July 23, 2003

Schwartz, G. E. (1990). Psychobiology of repression and health: A systems approach. In J. L. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health. Chicago: University of Chicago Press.

Wellness Reproductions. (1991). Anger management. Retrieved July 23, 2003

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482766
2003-12-00
Author: Eileen K. Hogan

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

Many different strategies and skills for anger management intervention have been tried and tested. Some of the most empirically supported interventions are cognitive-behavioral interventions including relaxation coping skills, cognitive interventions, behavioral coping and social skills training, and problem-solving skills training.

According to Dahlen and Deffenbacher (2001), relaxation coping skills target both the emotional and physiological arousal associated with anger with the intent being to lower the anger arousal. In contrast to targeting arousal, cognitive interventions target biases in information processing and cognitive appraisals. They help to identify distorted patterns of thinking, develop more reality-based and less anger-engendering cognitions, and free up problem-solving and coping resources.

Behavioral coping and social skills training target the actual expression of anger (vs. reducing anger arousal). Specific skills training that has been empirically supported includes direct coping skills (e.g., interpersonal communication, negotiation, feedback), related coping skills (e.g., parenting, budgeting and financial planning, assertive communication), and inductive social skills training (e.g., clients identify and explore effective behaviors for coping with anger) (Dahlen and Deffenbacher, 2001).

Problem-solving skills training is useful when there are no behavioral skill deficits (e.g., poor social skills) but there is a lack of general problem-solving skills with which to assess situations and to choose various coping skills. A basic problem-solving methodology is to identify the problem, generate alternative solutions, consider theconsequences of each solution, select an effective and appropriate response, and evaluate the outcomes of implementing the specific response (Skiba & McKelvey, 2000).

Additional strategies that have been found to be useful in managing anger effectively include avoiding situations that make one angry, changing environments, focusing on something positive, engaging in substitute positive activities, and improving communication and social skills. Humor has also been found to be helpful when it is used constructively to help face problems; sarcastic humor is just another form of unhealthy anger expression (Controlling anger before it controls you, n.d.).

Structured Programs

In addition to the strategies and skills highlighted above, there are numerous structured and pre-packaged programs for helping people learn to manage their anger more effectively. These programs vary in intended audience, theoretical basis, teaching method, and actual skills and techniques used. A summary of several programs can be found in Anger Management 3: Structured Interventions.

Additional Considerations in Anger Management Interventions

Cultural Impact of Client's Natural Environment

Howells and Day (2002) highlight the importance of understanding the culture a client returns to upon leaving a counseling or training session. Will the culture support the behavior changes and thinking processes that the client has been learning? In some cases (e.g., the gang a client hangs out with, incarcerated clients, institutionalized clients), the culture the client lives in day-to-day will not necessarily support the kinds of changes a client may be trying to make.

Indeed, daily survival may be based on vastly different modes of operation than a client may be practicing in counseling. It is important to clarify which culture is in charge of the client's daily life (e.g., the family and its subcultures? the street corner and friends? the neighborhood? the school and teachers?) and how it may affect a client's success in learning to manage anger more effectively.

Transferring Skills to the Classroom, Workplace, and Home

Another consideration is the adequate transfer of skills learned in counseling to one's natural environment. This could be the classroom, the workplace, or even one's home. Besley (1999) conducted an experiment on transferring skills to the classroom environment of a student client.

According to Besley (1999), change begins at a teachable moment, and four conditions are necessary for change:

• the person is in an environment where he or she feels safe,
• the person is supported and encouraged during the change process,
• the environment is relevant to the person, and
• the person is involved and has some degree of control in the change process.

In a school setting, when a counselor has been working with a student individually to develop more effective anger management skills, there still remains the issue of encouraging the student to use the new skills outside the counseling sessions (e.g., in the classroom, in the cafeteria, on the playground). One proven way to do this is to have the counselor sit in the classroom (or cafeteria or playground) with the student and be available to coach the student right at the moment(s) he or she becomes angry (Besley, 1999). The counselor can then coach the student's cognitive processes and help the student cope with impulsivity and, at the same time, model effective and useful skills for the other students and even the teacher.

Readiness for Anger Management Intervention

The best anger management training delivered by the most qualified counselor will be ineffective if the client is not ready for anger management training. According to Howells & Day (2003), there are several different things that can impact readiness for anger management.

Sometimes there are a complex array of factors presenting with the anger problem. People with certain mental and personality disorders may also have an anger management problem. Or anger management and control may be a symptom of a serious mental or personality disorder.

Existing client inferences about their anger "problem" can impact their readiness. Some clients may view anger as an appropriate response to many situations. Some clients may believe that catharsis is the best approach (expressing anger is considered better than controlling it) or that angry responses get results (in reality, although angry outbursts sometimes generate desired short- term results, they rarely result in long-term change). Attitudes of self-righteousness, low personal responsibility, blaming others, and condemning others also reduce readiness. For some clients, anger may not even be considered a problem. In fact, anger may be adaptive in certain settings for the client: it may bring with it many social benefits such as perceptions of higher status, strength, and competence. Unfortunately, these types of beliefs and perceptions can be difficult to uncover and assess.

The client's skill level also impacts readiness for effective treatment. People need certain cognitive processes with which to think about consequences and choices in order to improve anger management skills. Sometimes a person's impulsive nature will interfere with the application of such cognitive processes. Other issues that impact a client's readiness are difficulty judging the intent of others, underestimating one's own reaction to anger-provoking situations, wanting to blame conflict on others, an inability to distinguish one's feelings, and poor social and problem-solving skills.

Finally, the client's beliefs about treatment impact readiness. Even in coerced or mandatory treatment, if the client concurs with the need for treatment and perceives the treatment as likely to be helpful in meeting his or her goals, then coercion is not as big an issue. However, if the client believes the treatment is not likely to fulfill his or her personal goals, then coercion could definitely impact readiness.

How does a counselor positively influence the readiness variables? Counselors can explore the personal goals of the client and help the client become aware of any discrepancies between the actual social consequences of their anger expression and the pursuit of their personal goals. Counselors can work to incorporate the client's goals and treatment plan into the values and goals of the existing informal culture of the client.

Counselors can also help clients build appropriate interpersonal and cognitive skills and develop an appropriate vocabulary for communicating triggers, thoughts, emotions, and behaviors.

Variables that Influence Effective Treatment

In studies on the effect of anger management interventions with student populations, Skiba and McKelvey (2000) found three variables to have the most influence. First, the length of treatment: typically, more sessions yield stronger initial outcomes and booster sessions (e.g., annually) improve long-term outcomes. Second, proper framing: the more the training is made relevant to the student and the environments in which he or she lives on a daily basis, the stronger the initial outcomes. Finally, supplemental interventions (e.g., utilizing weekly goals, utilizing components of Aggression Replacement Training) help improve initial outcomes. Although these factors were studied specifically in reference to student populations, they are likely applicable to other client bases as well.

Summary

Anger. Everybody experiences it and everybody expresses it. Some people manage their anger in healthy ways. Other people are managed by their anger in unhealthy ways. Although there are many skills, strategies, and structured programs (see Anger Management 3: Structured Interventions) known to help people improve how they deal with anger, there are many factors to consider when selecting an effective intervention. In addition to understanding the expression, function, source, and resulting problems of a client's anger (see Anger Management 1: An Overview for Counselors), practitioners can also attempt to understand the client's cultural needs with respect to dealing with the problem, the ability of the client to transfer new skills to their daily environments, and the client's readiness and skill level for dealing with the problem. Only then can the practitioner choose an intervention that will be truly effective for the client.

For more information please see: Anger Management 1: An Overview for Counselors

References

Besley, K. R. (1999). Anger management: Immediate intervention by counselor coach. Professional School Counseling, 3(2), pp. 81-90.

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association.

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J. V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Howells, K. & Day, A. (2003). Readiness for anger management: clinical and theoretical issues. Clinical Psychology Review, 23. pp. 319-337.

Skiba, R. & McKelvey, J. (2000). What works in preventing school violence: The safe and responsive fact sheet series - Anger management. Retrieved July 23, 2003 from What works in preventing school violence

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482767
2003-12-00
Author: Eileen K. Hogan

Page last modified or reviewed by athealth on August 27, 2018