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Panic attacks in and of themselves are powerful agents for eroding confidence. Suddenly, you feel unable to do all sorts of things you used to do, all sorts of things "normal" people do. On top of that, you feel as though you've lost control of your own body, something so basic to your sense of self that you probably never even gave it a second thought before the attacks hit.

Panic sufferers often describe themselves as "people-pleasers" who find it extremely painful to risk others' dislike or disapproval. They may agree to others' requests, suppress their own opinions, and put the needs of others before their own - sometimes to the point that they almost lose touch with their own wishes and feelings. As one woman put it, "I'll turn myself inside out for you if it will get you to say just one nice thing about me."

There are many reasons why people find it difficult to assert themselves. One important reason relates to fears of loss: you may feel you'll put a relationship at risk if you assert yourself too forcefully. Or you may lack the confidence and self-esteem to express your own wishes, perhaps seeing them as unimportant.

Maybe you're so tender-hearted that you can't bear to refuse anyone anything. Or you may have become so accustomed to the role of "giver" in your family of origin that it scarcely occurs to you to refuse.

Many panic sufferers describe themselves as perfectionists who feel it's a sign of "laziness" or "weakness" or "selfishness" to refuse another's request. And still others hold strong religious beliefs about the importance of giving that makes it hard to know where to draw the line. In short, for any number of reasons, you feel obligated to give and give and give some more - even when you feel there's nothing left, even if it leads to resentment inside.

In addition to losing confidence as a result of panic disorder, many panic sufferers say they struggled with feelings of inadequacy before their attacks first began (and sometimes with a need to rely too much on others as a result). If you're someone who's battled with a lack of confidence in the past, it's worth spending a few minutes to consider the sources of those feelings, so you can fight back more effectively.

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Adapted from Master Your Panic and Take Back Your Life! Twelve Treatment Sessions to Conquer Panic, Anxiety and Agoraphobia (3rd Ed.), by Denise F. Beckfield, Ph.D. Available at online and local bookstores or directly from Impact Publishers, PO Box 6016 , Atascadero , CA 93423-6016 , www.bibliotherapy.com or phone 1-800-246-7228.

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Reviewed by athealth on February 8, 2014.

All parents struggle with some of the things their children do. While there is no magic formula that will work in all situations, it is helpful to understand the kinds of issues that impact a child's behavior. If you understand these issues and know what to expect at different developmental stages, your reactions will be wiser and it will be easier to create an environment that supports and nurtures your child.

When your child's behavior is troubling, ask yourself:

• Is this a growth or developmental stage?Each new phase of growth or development brings challenges for the child and the child's caregivers. For example, growing independence in the child's second year is often accompanied by challenging behavior (such as the "No!" phase). Feeding and sleeping problems may occur during developmental transitions, and it helps if caregivers are extra patient and loving in their responses. It's best to give the child choices, use humor, and be firm but supportive.
• Is this an individual or temperament difference?Not all children of a certain age act the same way. Some progress developmentally at different rates, and all have their own temperaments that may account for differences in behavior. Being aware of a child's tendency to be shy, moody, adaptable, or inflexible will help you better understand the child's behavior in a specific situation and impact the way you approach the behavior.
• Is the environment causing the behavior?Sometimes the setting provokes a behavior that may seem inappropriate. An overcrowded living or childcare arrangement coupled with a lack of toys can increase aggression or spark jealousy. Look around your home to evaluate it in light of your child's behaviors and see the environment from a child's viewpoint.
• Does the child know what is expected?If a child is in a new or unfamiliar territory or is facing a new task or problem, he or she may not know what behavior is appropriate and expected. Perhaps this is the first time a two-year-old without siblings has been asked to share a toy. Developmentally he does not truly understand the concept of sharing, so it is up to the parent to explain calmly how other children will react. Patience and repeating the message over and over again are necessary as children rarely learn or master a new response on the first try.
• Is the child expressing unmet emotional needs?Emotional needs that are unmet are the most difficult cause of behavior to interpret. If a particular child needs extra love and attention, rather than withhold that from her, it will be helpful to find ways to validate and acknowledge the child more frequently.

Adapted from Understanding Behavior: A Key to Discipline, National Association for the Education of Young Children and Judy Reinsberg, July 1999
Source: Adapted from U.S. Department of Health and Human Services, Administration for Children and Families (ACF). (2006.) Safe children and healthy families are a shared responsibility: 2006 community resource packet: http://www.childwelfare.gov/preventing/pdfs/understanding.pdf

Reviewed by athealth on February 8, 2014.

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

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

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

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

Older Women Have Increased Risks for Alcohol Problems

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

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

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

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

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

Prevalence of the Problem

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

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

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

Risk and Benefits Associated with Alcohol Use by Older Women

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

Risks

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

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

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

Benefits

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

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

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

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

Drinking Guidelines and Rationale

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

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

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

Definitions

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

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

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

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

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

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

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

Screening and Detection of Alcohol Problems in Older Women

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

Signs and Symptoms of Alcohol Problems in Older Women Anxiety Increased tolerance to alcohol or medications Depression, mood swings Memory loss Disorientation New difficulties in decisionmaking Poor hygiene Falls, bruises, burns Family problems Idiopathic seizures (i.e., seizures with an unknown origin or cause) Financial problems Sleep problems Headaches Social isolation Incontinence Poor nutrition SOURCE: Adapted from Barry et al. 2001.

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

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

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

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

Prevention, Brief Intervention, and Formal Treatment with Older Women

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

Brief Alcohol Intervention Goals

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

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

Effectiveness of Brief Alcohol Interventions with Older At-Risk Drinkers

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

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

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

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

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

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

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

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

Formal, Specialized Treatment Approaches for Older Women

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

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

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

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

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

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

Summary

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

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

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

References

1. ABRAMSON, J.L.; WILLIAMS, S.A.; KRUMHOLZ, H.M.; and VACCARINO, V. Moderate alcohol consumption and risk of heart failure among older persons. JAMA: Journal of the American Medical Association 285(15):1971-1977, 2001.
2. ADAMS, W.L.; BARRY, K.L.; and FLEMING, M.F. Screening for problem drinking in older primary care patients. JAMA: Journal of the American Medical Association 276(24):1964-1967, 1996.
3. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA, 1994.
4. ATKINSON, R. Treatment programs for aging alcoholics. In: Beresford, T.P., and Gomberg, E.S.L., eds. Alcohol and Aging. New York: Oxford University Press, 1995. pp. 186-210.
5. BARRY, K.L. Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series No. 34. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1999.
6. BARRY, K.L.; OSLIN, D.; and BLOW, F.C. Prevention and Management of Alcohol Problems in Older Adults. New York: Springer Publishing, 2001.
7. BITTNER, V; SIMON, J.A.; FONG, J.; et al. Correlates of high HDL cholesterol among women with coronary heart disease. American Heart Journal 139(2):288-296, 2000.
8. BLOW, F. Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series No. 26. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1998.
9. BLOW, F.C., and BARRY, K.L. Older patients with at-risk and problem drinking patterns: New developments in brief interventions. Journal of Geriatric Psychiatry and Neurology 13(3):115-123, 2000.
10. BLOW, F.; GILLESPIE, B.W.; BARRY, K.L.; et al. "Brief screening for alcohol problems in elderly populations using the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)." Paper presented at the Research Society on Alcoholism Annual Scientific Meeting, Hilton Head Island, SC, June 20-25, 1998.
11. BLOW, F.C.; WALTON, M.A.; CHERMACK, S.T.; et al. Older adult treatment outcomes following elder-specific inpatient alcoholism treatment. Journal of Substance Abuse Treatment 19:67-75, 2000.
12. BROE, G.A.; CREASEY, H.; JORM, A.F.; et al. Health habits and risk of cognitive impairment and dementia in old age: A prospective study on the effects of exercise, smoking and alcohol consumption. Australian and New Zealand Journal of Public Health 22(5):621-623, 1998.
13. Collaborative Group on Hormonal Factors in Breast Cancer. Alcohol, tobacco and breast cancer: Collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer 87(11): 1234-1245, 2002.
14. DUFOUR, M.C., and FULLER, R.K. Alcohol in the elderly. Annual Review of Medicine 46:123-132, 1995.
15. ENSRUD, K.E.; NEVITT, M.C.; YUNIS, C.; et al. Correlates of impaired function in older women. Journal of the American Geriatrics Society 42:481-489, 1994.
16. EWING, J.A. Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association252(14):1905-1907, 1984.
17. FINLAYSON, R.E.; HURT, R.D.; DAVIS, L.J., Jr.; and MORSE, R.M. Alcoholism in elderly persons: A study of the psychiatric and psychosocial features of 216 inpatients. Mayo Clinic Proceedings 63:761-768, 1988.
18. FLEMING, M.F.; BARRY, K.L.; MANWELL, L.B.; et al. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. JAMA: Journal of the American Medical Association 277(13):1039-1045, 1997.
19. FLEMING, M.F.; MANWELL, L.B.; BARRY, K.L.; et al. Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice 48(5):378-384, 1999.
20. GAMBERT, S.R., and KATSOYANNIS, K.K. Alcohol-related medical disorders of older heavy drinkers. In: Beresford, T.P., and Gomberg, E., eds. Alcohol and Aging. New York: Oxford University Press, 1995. pp. 70-81.
21. GRAHAM, K., and SCHMIDT, G. Alcohol use and psychosocial well-being among older adults. Journal of Studies on Alcohol 60:345-351, 1999.
22. Institute of Medicine. Broadening the Base of Treatment for Alcoholism. Washington, DC: National Academy Press, 1990. pp. 242-278.
23. KLATSKY, A.L.; ARMSTRONG, M.A.; and FRIEDMAN, G.D. Red wine, white wine, liquor, beer, and risk for coronary artery disease hospitalization. American Journal of Cardiology 80(4):416-420, 1997.
24. MILLER, W.R., and ROLLNICK, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.
25. MOORE, A.A.; MORTON, S.C.; BECK, J.C.; et al. A new paradigm for alcohol use in older persons. Medical Care37(2):165-179, 1999.
26. MUKAMAL, K.J., and RIMM, E.B. Alcohol's effect on the risk of coronary heart disease. Alcohol Research & Health25(4):255-261, 2001.
27. NELSON, H.D.; NEVITT, M.C.; SCOTT, J.C.; et al. Smoking, alcohol, and neuromuscular and physical function of older women. JAMA: Journal of the American Medical Association 272:1825-1831, 1994.
28. ORGOGOZO, J.M.; DARTIGUES, J.F.; LAFONT, S.; et al. Wine consumption and dementia in the elderly: A prospective community study in the Bordeaux area. Revue Neurologique (Paris) 153(3):185-192, 1997.
29. SAUNDERS, P.A.; COPELAND, J.R.; DEWEY, M.E.; et al. Heavy drinking as a risk factor for depression and dementia in elderly men. British Journal of Psychiatry 159:213-216, 1991.
30. SCHERR, P.A.; LACROIX, A.Z.; WALLACE, R.B.; et al. Light to moderate alcohol consumption and mortality in the elderly. Journal of the American Geriatrics Society 40:651-657, 1992.
31. SCHONFELD, L.; DUPREE, L.W.; DICKSON-FUHRMANN, E.; et al. Cognitive-behavioral treatment of older veterans with substance abuse problems. Journal of Geriatric Psychiatry and Neurology 13(3):124-129, 2000.
32. SCHROTT, H.G.; BITTNER, V.; VITTINGHOFF, E.; et al. Adherence to National Cholesterol Education Program treatment goals in postmenopausal women with heart disease. The Heart and Estrogen/Progestigen Replacement Study (HERS). JAMA: Journal of the American Medical Association 277(16):1281-1286, 1997.
33. SELLERS, T.A.; VIERKANT, R.A.; CERHAN, J.R.; et al. Interaction of dietary folate intake, alcohol, and risk of hormone receptor-defined breast cancer in a prospective study of postmenopausal women. Cancer Epidemiology 11:1104-1107, 2002.
34. SIMONS, L.A.; MCCALLUM, J.; FRIEDLANDER, Y.; et al. Moderate alcohol intake is associated with survival in the elderly: The Dubbo study. Medical Journal of Australia 173(3):121-123, 2000.
35. SMITH, J.W. Medical manifestations of alcoholism in the elderly. International Journal of the Addictions 30(13 and 14):1749-1798, 1995.
36. THOMAS, V.S., and ROCKWOOD, K.J. Alcohol abuse, cognitive impairment, and mortality among older people.Journal of the American Geriatric Society 49:415-420, 2001.
37. THUN, M.J.; PETO, R.; LOPEZ, A.D.; et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. New England Journal of Medicine 337(24):1705-1714, 1997.
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40. VESTAL, R.E.; MCGUIRE, E.A.; TOBIN, J.D.; et al. Aging and ethanol metabolism. Clinical Pharmacology and Therapeutics 21:343-354, 1977.
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Source: National Institute on Alcohol Abuse and Alcoholism
June 2003
By Frederic C. Blow, PhD, and Kristen Lawton Barry, PhD

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Reviewed by athealth on February 8, 2014.

There are many things you can do to help children with their fears. You also can share ideas with parents or caregivers when you talk with them. These are ways you can help children at home, at school, or in the community.

1. Accept and respect children's fears. Fears are real to children; don't laugh or pretend their fears are not real. Although children will grow out of some of their fears, you can help children learn ways to deal with their fears. These skills will help them for the rest of their life.

2. Spend extra time with children when they are afraid. Help children adjust to childcare when they are new in your program. Some children need special attention during storms. Bedtime is another time when some children need special attention, because other fears look larger when they are combined with fears of the dark. Bedtime routines like a song or a story can be comforting.

3. Establish a predictable routine. Knowing patterns in daily life makes children feel secure in their world. It helps them to know what to expect. At childcare, you can follow the same pattern of activities each day - snack, large group time, outdoor play. There can be a routine at home too. In some families, one day each week the children help get groceries. Maybe the children have a bath after dinner. In some families, there is a bedtime story each night. In other homes, parents always sing a song before the children go to sleep.

4. Talk about feeling scared. It is important for children to learn to talk about all of their feelings, including fear. When children look like they are scared, you can say to them, "You are biting your fingernails. Does that mean you feel scared?" This helps children to name what they feel. You will begin to understand how each child shows fears. Some children will suck their thumbs. Some will fidget. Some will whine and complain more. When you talk with them about being scared, it helps them to learn to talk about their feelings.

5. Use play to talk about fears. Dolls, stories, and art can help children talk about being afraid. Play-acting gives children a sense of control over their fears. Ask them to talk about pictures they made. Playing is especially useful to prepare for big changes. For example, before moving to a new house, play out what will happen on moving day. Build two houses out of blocks and use a toy truck to move the furniture. This will help the children understand what it means to move. Read books about fears with the children.

6. Help the children learn about what scares them. Knowing how things work and what to expect can make things less scary. Read books about why fire trucks have sirens, or learn about thunder and lightning. Let children know that it is okay to be a little afraid of some things. It can be good to be a little scared of dogs you don't know or strangers who ask you to get in their car.

7. Talk about your fears, too. Children need to know that adults have different kinds of feelings, too. They need to see how adults deal with feelings like fear. Talk about your feelings so children learn to express their feelings with words, but be careful not to tell children things that will scare them. Don't add to their worries. Be careful not to protect them too much, but don't tell them too much. Think about how much children needs to know about stressful events that might scare them. Talk about how fear makes you feel in your body. Tell them what you do to feel better when you are afraid. That can teach children that everyone can learn to live with and manage fears.

8. Recognize courage. Tell children when you notice them trying something that scares them. Tell them you are proud when they act brave. For example you could say, "When we walked by the dog, you didn't ask to be picked up. You just held my hand tightly. Good for you! You are becoming brave!" This encourages them.

9. Talk about what might help them cope with their fear. Ask the children what would help them feel less afraid. Asking children what will help them deal with their fears helps them learn problem-solving skills. Talk about how you coped with fears when you were a child. Teach children how to take slow, deep breaths to relax and feel better. If pictures of bombs and shooting scare children, tell them they can turn off the TV or walk away. Limit war play and violence in the childcare setting. If children are scared of the dark, put their cots or mats closer to the windows so they have more light.

Source: Provider-Parent Partnerships
http://www.ces.purdue.edu/providerparent/index.htm
Purdue University, School of Consumer and Family Sciences
Department of Child Development and Family Studies
Authors: Giselle Goetz with Judith A. Myers-Walls, PhD, CFLE

Reviewed by athealth on February 8, 2014.

There are many terms used to describe approaches to health care that are outside the realm of conventional medicine as practiced in the United States. This fact sheet explains how the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health, defines some of the key terms used in the field of complementary and alternative medicine (CAM). A dictionary of terms that are underlined in the text can be found at the end of this fact sheet.

What is complementary and alternative medicine?

Complementary and alternative medicine, as defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.^1,2 While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used.

The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.

Are complementary medicine and alternative medicine different from each other?

Yes, they are different.

• Complementary medicine is used together with conventional medicine. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery.
• Alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.

What is integrative medicine?

Integrative medicine, as defined by NCCAM, combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.

What are the major types of complementary and alternative medicine?

NCCAM classifies CAM therapies into five categories, or domains:

• Alternative Medical Systems
  Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.
• Mind-Body Interventions
  Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.
• Biologically Based Therapies
  Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements,³ herbal products, and the use of other so-called "natural" but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).
• Manipulative and Body-Based Methods
  Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.

Energy Therapies


Energy therapies involve the use of energy fields. They are of two types:

• Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.
• Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields.

What is NCCAM's role in the field of complementary and alternative medicine?


NCCAM is the Federal Government's lead agency for scientific research on complementary and alternative medicine. NCCAM's mission is to explore complementary and alternative healing practices in the context of rigorous science, to train CAM researchers, and to inform the public and health professionals about the results of CAM research studies.

Notes ¹ Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Other terms for conventional medicine include allopathy; Western, mainstream, orthodox, and regular medicine; and biomedicine. Some conventional medical practitioners are also practitioners of CAM.

² Other terms for complementary and alternative medicine include unconventional, non-conventional, unproven, and irregular medicine or health care.

³ Some uses of dietary supplements have been incorporated into conventional medicine. For example, scientists have found that folic acid prevents certain birth defects, and a regimen of vitamins and zinc can slow the progression of an eye disease called age-related macular degeneration (AMD).

Dictionary of Terms


Aromatherapy ("ah-roam-uh-THER-ah-py"): Aromatherapy involves the use of essential oils (extracts or essences) from flowers, herbs, and trees to promote health and well-being.

Ayurveda ("ah-yur-VAY-dah") is a CAM alternative medical system that has been practiced primarily in the Indian subcontinent for 5,000 years. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment.

Chiropractic ("ki-roh-PRAC-tic") is a CAM alternative medical system. It focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool.

Dietary supplements: Congress defined the term "dietary supplement" in the Dietary Supplement Health and Education Act (DSHEA) of 1994. A dietary supplement is a product (other than tobacco) taken by mouth that contains a "dietary ingredient" intended to supplement the diet. Dietary ingredients may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, and metabolites. Dietary supplements come in many forms, including extracts, concentrates, tablets, capsules, gelcaps, liquids, and powders. They have special requirements for labeling. Under DSHEA, dietary supplements are considered foods, not drugs.

Electromagnetic fields: Electromagnetic fields (EMFs, also called electric and magnetic fields) are invisible lines of force that surround all electrical devices. The Earth also produces EMFs; electric fields are produced when there is thunderstorm activity, and magnetic fields are believed to be produced by electric currents flowing at the Earth's core.

Homeopathic ("home-ee-oh-PATH-ic") medicine is a CAM alternative medical system. In homeopathic medicine, there is a belief that "like cures like" meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses would actually cause those symptoms.

Massage ("muh-SAHJ") therapists manipulate muscle and connective tissue to enhance function of those tissues and promote relaxation and well-being.

Naturopathic ("nay-chur-o-PATH-ic") medicine is a CAM alternative medical system in which practitioners work with natural healing forces within the body, with a goal of helping the body heal from disease and attain better health. Practices may include dietary modifications, massage, exercise, acupuncture, minor surgery, and various other interventions.

Osteopathic ("ahs-tee-oh-PATH-ic") medicine is a form of conventional medicine that, in part, emphasizes diseases arising in the musculoskeletal system. There is an underlying belief that all of the body's systems work together, and disturbances in one system may affect function elsewhere in the body. Some osteopathic physicians practice osteopathic manipulation, a full-body system of hands-on techniques to alleviate pain, restore function, and promote health and well-being.

Qi gong ("chee-GUNG") is a component of traditional Chinese medicine that combines movement, meditation, and regulation of breathing to enhance the flow of qi (an ancient term given to what is believed to be vital energy) in the body, improve blood circulation, and enhance immune function.

Reiki ("RAY-kee") is a Japanese word representing Universal Life Energy. Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.

Therapeutic Touch is derived from an ancient technique called laying-on of hands. It is based on the premise that it is the healing force of the therapist that affects the patient's recovery; healing is promoted when the body's energies are in balance; and, by passing their hands over the patient, healers can identify energy imbalances.

Resources


For more information on CAM or NCCAM, contact:

NCCAM Clearinghouse
NCCAM Web site: http://www.nccam.nih.gov

NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy in this information is not an endorsement by NCCAM.

Source: National Center for Complementary and Alternative Medicine
Updated February 2004

Reviewed by athealth on February 8, 2014.

Smallest patient offers biggest lesson

By Bruce Himelstein and Joanne Hilden

Jennifer Phelan knows it’s possible to survive the unthinkable. She knows because her 7-year-old daughter showed her how.

Phelan’s education started in June of 1999, when her only child, Georgiana Antonopoulos, was diagnosed with lymphoma, a cancer of the blood. It ended last November, as she watched the little girl she called Georgie, surrounded by friends and family, die peacefully on the oncology ward in the Children’s Hospital of Philadelphia.

From the moment Georgiana was diagnosed, all Phelan could think about was losing her daughter. She didn’t talk about it, though, “because I was told it was normal to feel that way. … And I don’t know if I feared more her dying than I did a relapse. Sure enough, that came true.

“When she relapsed, I knew she wouldn’t make it. I didn’t want to feel that way, but I did. I didn’t tell anybody that, because I was afraid I would get yelled at, having to say something like that or feel something like that, so I did whatever (my doctor) wanted to do as far as the chemo(therapy).”

When the disease failed to respond, her primary care oncologist, Dr. Susan Rheingold, mentioned pediatric palliative care as an option.

What Phelan and her daughter would experience for the next two months is a quietly growing medical specialty that includes the smallest dying patients and their families in critical medical decisions. Teams of specialists work together to tend to the emotional, psychological, practical and spiritual needs of the patient and family — and that stay with the child as he or she moves through the health care system.

Child life specialists, psychologists, hospice professionals, social workers and spiritual counselors are called in to help the family say their goodbyes and prepare for what lies ahead.

In the last few months of her life, Georgiana was getting the kind of comprehensive palliative care not widely incorporated into the mainstream medical system for children with life-threatening illnesses — mainly because no one wants to deal with the fact that children die.

Advocates battle the perception that once a child is put under palliative care, doctors have given up, and a search for a cure stops. It’s a perception Jennifer Phelan faced squarely.

“I must stress how much I hated having to experience palliative care, as I know you know this all too well,” Phelan wrote in an e-mail to a team member after Georgiana died. “But the team was so comforting and so very compassionate. I think that is so important because I, as many other parents, was given the worst news imaginable.”

Or, as Steve Simms, the psychologist who worked with the family, put it, “Palliative care meant death and letting go. It meant that Jennifer was going to lose her daughter. It was the shattering of the myth that (the hospital) would find the cure. She dreaded the day you would darken her door.”

Once Georgiana was admitted, her hospital room immediately was transformed into a home-like setting. Her parents brought her teddy bear and “baby blanket,” which she had slept with every night since she was born. Georgiana hated the hospital-issued pajamas and socks, so she brought in her own “funky” footwear. Helping her get to sleep was a wind-up music box that played “Winnie the Pooh” and a bright green frog light.

The team treated and spoke to Georgiana daily, while conferring with her two sets of parents — Jennifer and her husband, and Georgiana’s father and his wife.

Unlike her parents, Georgiana quickly came to terms with her condition.

Team members caring for dying children frequently recognize the depth of their patients’ perception and awareness. Children often know when they are dying.

Phelan describes it simply: “I see the doctor. My mommy leaves the room. I come back in crying. She put it together. You can’t hide it from them. They’re going to figure it out on their own.”

As Georgiana got sicker, her mother recalls her asking, “Mom, am I going to die?”

“And I couldn’t answer her. I said, ‘I don’t know.’ I said, ‘That’s what we we're all afraid of because the medicine didn’t work.’ And she cried. And that was it — she stopped and went to do whatever she was doing.”

Afterward, Georgiana spoke openly with her primary nurse about how snowflakes and ladybugs could come together in heaven. She drew a smiling self-portrait of herself in heaven just a few days before her death.

“I also think it was important that Georgiana had (a child psychologist) talk to her and I think she helped her a whole lot,” said Phelan. “She knew why this woman was coming in to talk to her. After a few times she looked forward to it…. I guess because she thought that she was (just) going to talk to her and it wasn’t all talk — it was through play. I guess we found out a lot through that …”

It took encouragement from the team, however, before Phelan could speak openly with Georgiana about dying. “It was hard, but I’m glad I did it,” said Phelan. “Because she said she wasn’t scared, and she didn’t think about it. I asked her, and it was the way she said it that makes me feel a little better now. Her fear was leaving us. She had said to me, ‘If I die, I won’t see you anymore.’ And I told her she would, because she could watch us from heaven. And then she didn’t talk about it again.

“She said that every night when I go to bed she’ll come in my room and give me a kiss,” Phelan said.

As Georgiana’s condition worsened, her doctor and the palliative care team discussed the family’s options, including if, when and how to let her die naturally: Stopping the antibiotics. No more trips to the intensive care unit. Whether to set up hospice care at home. Saying no to life support systems. And planning for a funeral.

“When we couldn’t get Georgie into remission and the chance of a bone marrow transplant was practically nil, Jennifer investigated the options, but didn’t want to put Georgie through more,” Rheingold said. “Jennifer’s maturity was astounding from the first discussion of palliative care on. Whereas some families want to try anything to prolong their child’s life or continue to hope for a cure, not always thinking of the cost to the child and quality of life issues, the quality of Georgiana’s life was always first and foremost for Jennifer.”

“The hardest decision was stopping those antibiotics,” Phelan recalled. “But I knew I didn’t want Georgie on a tube (life support machine). I mean, I don’t think I could’ve seen her like that, because she wasn’t going to live anyway and she wouldn’t want to be that way. I think if I had done anything else it would have been for me, not her. That would’ve been selfish … I just wouldn’t do it.”

As death neared, managing Georgiana’s pain with morphine became everyone’s No. 1 priority.

“I remember at the funeral the priest saying — he was trying to be comforting but so far from knowing what it was really like those past months — that ‘now she wasn’t suffering anymore,’” recalled Rheingold. “It pissed me off, as Jennifer and we had tried so hard not to make her suffer.”

Phelan later wrote to the team: “I can still hear you telling me on Friday, the 24th of November, ‘She should pass within the next day or two ...’ Sure enough, you were exactly right. I hated the truth, the reality of this nightmare, and I still do, but I appreciated the fact that nobody sugar-coated it.”

Phelan remains in contact with Georgiana’s nurses, her primary physician, and the palliative care team even now. “I can’t even begin to tell you how much I think these contacts are helpful. I developed relationships with these people. They were there for me to talk to and, most of all, they were there for Georgie.”

Phelan is part of an online bereavement group and attends support groups at the hospital. She recognizes that she and her husband are grieving differently: “He wants to socialize. I want to be alone.” She’s also making a picture quilt, a legacy to her daughter.

Phelan has found that because she has been through the unthinkable, she’s treated a little too gently — or not at all — by friends and acquaintances. But she has a message for them about acceptance, something else she learned from her little girl.

“I guess people are uncomfortable,” she says. “They don’t know what to say to me. I get that look, you know, like ‘that’s Georgiana’s mom.’ It’s all right, it’s OK. I’m still here, you can talk to me. Just come up and say hi to me. People ignore you. They don’t know what to say. I feel like just saying, ‘Hello, it’s OK.’”

For Rheingold and the palliative care team, that’s the ultimate goal.

“Of my three patients that have died I feel this was the most comfortable for all involved — Georgie, her family and me,” she said. “It is always hard to see a child die, but I felt that we worked together as a team to make it the best possible death — if those words can be used together in the same sentence.’’

Copyright © 2005 National Hospice and Palliative Care Organization
All rights reserved. Reprinted with permission.

Reviewed January 27, 2014

When Terrorists Strike: What School Counselors Can Do

Terrorist attacks in New York City and Washington, DC, and the continued threats of terrorism have the potential to engender negative psychological effects upon school age children and their families. School counselors and mental health professionals working with children need to be knowledgeable regarding interventions which allow students to openly discuss immediate and future concerns, cumulative stressors resulting from on-going terrorist threats, and post-terrorism psychopathology (e.g., anxiety, distress, etc.). This digest will familiarize readers with basic Critical Incident Stress Debriefings (CISD), outline the differences between CISD and the Adapted Family Debriefing Model for school students, and describe how mental health professionals can use this model as a post-terrorism response intervention.

Critical Incident Stress Debriefing vs The Adapted Family Debriefing

Model for School Students

Critical Incident Stress Debriefing (CISD) is a seven-stage, small group process originally developed for use with adult emergency workers who encounter particularly distressing situations (Mitchell & Everly, 1993). Some have cited CISD as a viable intervention with children and adolescents who experience violence or suicide (O'Hara, Taylor, & Simpson, 1994; Thompson, 1990). Yet, CISD was developed solely for adult use and did not take into account the special developmental needs of children. The Adapted Family Debriefing Model, however, was developed as an assessment and intervention method for student populations exposed to violence (Juhnke, 1997). Evolved from CISD's single group experience, the Adapted Family Debriefing Model for school students requires two separate debriefing experiences. The first debriefing experience is with students' parents only. The second is a joint student-parent debriefing experience. Additionally, unlike the CISD process which utilizes nonprofessional, adult peer facilitators, the Adapted Family Debriefing Model for school students requires the use of trained mental health professionals who have specific knowledge regarding children's developmental needs.

Description

Roles

The primary team members within the Adapted Family Debriefing Model for school students are leader, co-leader, and doorkeeper. The leader explains the debriefing process, creates a supportive milieu, identifies those experiencing excessive levels of emotional discomfort, and directs team members via hand signals to intervene with distraught students or parents. In addition, the leader discusses with parents and students common symptoms experienced by children who:

(a) have personally experienced terrorist acts or have suffered loss as a result of such acts (e.g., the death of a grandparent or sibling resulting from terrorism, etc.),

(b) have witnessed via the media terrorist acts or the aftermath of same,

(c) understand the potential for continued terrorist acts, or

(d) experience the cumulative effects of multiple terrorist acts.

The leader normalizes manifest symptoms and encourages parents to recognize more severe symptomatology which may require additional counseling (e.g., recurrent encopresis, persistent outbursts of anger, chronic hypervigilance).

Co-leaders add relevant comments during the session and give immediate support to students and parents who become emotionally distraught. They also help prevent disruption that may otherwise inhibit group dynamics. The doorkeeper prevents nonparticipants, such as news journalists, from entering the session. Doorkeepers also prevent severely distraught students or parents from bolting from sessions.

Before the Debriefing

Before the debriefing, team members should be apprised of the circumstances surrounding the debriefing. For example, is the debriefing the result of the death of a fellow student from a terrorist act? Or, is the debriefing in response to cumulative effects of terrorist activities? Additionally, teams should learn whether or not students' parents are at increased risk due to their occupations or have a greater probability of being activated into military service. These factors will likely have an influence upon participants' moods and their perceptions of terrorist acts.

Separate Debriefings for Parents and Students

Parent and student needs are often different. Thus, the first session is conducted with parents. It is important to keep the number of parents small (i.e., fewer than 12). Parents often express frustration and anger regarding their inability to adequately protect their children from terrorism. Many will perceive the situation as "hopeless" and "out of their control." Thus, it is imperative that the team keeps parents focused on the immediate needs of their children. Promises of future student safety cannot be guaranteed and detract from the students' immediate needs. Parents need to be reminded that the goals of this session are to:

(a) learn about possible symptoms their children may exhibit,

(b) obtain available referral sources, and

(c) learn to validate and normalize their children's concerns.

During the joint student-parent debriefing, two circles are formed. No more than five or six students of similar ages should sit in the inner circle with friends or familiar peers presenting with similar concerns. Parents should sit behind their children, promoting a perception of stability, unity, and support.

Seven-Step Adapted Family Debriefing Model

1. Introduction step. During the introduction step, the leader identifies team members and establishes rules for the debriefing experience. Persons not directly related to the children or debriefing process are asked to leave. Confidentiality is explained in terms understandable to the students and participants are encouraged not to discuss what is said within the session outside the debriefing room. The leader states that the purpose of the session is to help students better understand their feelings about the specific terrorist act and increase their coping skills related to continued terrorist threats.

2. Fact gathering step. The second step of the process is fact gathering. The leader will ask the children to report what the experience of the terrorist act was like for them. Should the debriefing be related to terrorist acts which the students indirectly observed via media coverage, the leader may begin by asking about what the students saw on television. Those speaking are encouraged to state what they did when they first saw or heard about the terrorism. Emphasis is placed upon telling the facts of what each student encountered. However, should students begin sharing feelings, the leader and co-leaders should acknowledge emotions expressed and indicate that these feelings are normal.

3. Thought step. This transitional step helps participants move from the cognitive to the affective domain. The leader asks questions related to what students thought when the terrorism erupted. During this step it is crucial to continue to validate and normalize each student's reported thoughts and perceptions.

4. Reaction step. The thought step can quickly give way to the emotionally charged reaction step. Here, the focus should be kept upon participants' reactions to the terrorism. Typically, the leader will start with a question like, "What has been the most difficult part of seeing the airliner fly into the Twin Towers?"

5. Symptom step. During this step, the leader helps direct the group from the affective domain back to the cognitive domain. The leader uses age appropriate language to ask students about any physical, cognitive, or affective symptoms experienced since the violent episode. Often the leader will discuss symptoms such as nausea, trembling hands, inability to concentrate, or feelings of anxiety, asking those who have encountered such experiences to raise their hands. Such a show of hands helps normalize the described symptoms and often helps survivors experience relief.

6. Teaching step. Symptoms experienced by group members are reported in age appropriate ways as being both normal and expected. Possible future symptoms can be briefly described (e.g., reoccurring dreams of being attacked). This helps both parents and students better understand symptoms that they may encounter and gives permission to discuss such symptoms. During this step the group leader may ask, "What have you done or noticed your friends, teachers, and parents doing that have helped you handle this situation?" This question suggests that the students are doing well and helps them begin to look for signs of progress. Sometimes older students will express feelings of support from peers, teachers, or parents. Younger students may use active fantasy, such as pretending to be a hero, to help them better cope with their fears or concerns.

7. Re-entry step. The re-entry step attempts to place some closure on the experience and allows participants to discuss further concerns. The leader may ask students and parents to revisit pressing issues, discuss new topics or mention thoughts which might help the debriefing process come to a more successful end. After addressing any issues, the debriefing team makes a few closing comments related to group progress or support. A hand-out for students and another written for adults discussing common reaction symptoms can be helpful. Younger children may prefer drawing faces which depict how they currently feel (e.g., anxious, sad, frightened). Later parents can use these pictures as conversation starters with their children at home. Hand-outs should list a 24-hour helpline number and include the telephone number for the student's school counselor. Often, it is helpful to introduce parents to their child's school counselor at the debriefing.

Post-Session Activities

After the session, team members should mingle with parents and children as refreshments are served, looking for those who appear shaken or are experiencing severe distress. These persons should be encouraged to immediately meet with a counselor. The promotion of peer support (both parent and student) is important. Students and parents should be encouraged to telephone one another over the next few days to aid in the recovery process.

Summary & Conclusion

The Adapted Family Debriefing Model for school students described above demonstrates promise for helping both student survivors of terrorism and their parents cope with negative psychological and social effects. The model has distinct differences from traditional CISD and was developed specifically for students. The model is relatively easy to implement and can be modified to meet the needs of students and parents alike.

References

Juhnke, G. A. (1997). After school violence: An adapted critical incident stress debriefing model for student survivors and their parents. Elementary School Guidance & Counseling, 31, 163-170.

Mitchell, J. T., & Everly, G. S. (1993). Critical incident stress debriefing (CISD): An operations manual for the prevention of traumatic stress among emergency services and disaster workers. Ellicott City, MD: Chevron Press.

O'Hara, D. M., Taylor, R., & Simpson, K. (1994). Critical incident stress debriefing: Bereavement support in schools developing a role for an LEA education psychology service. Educational Psychology in Practice, 10, 27-33.

Thompson, R. (1990). Post-traumatic loss debriefing: Providing immediate support for survivors of suicide or sudden loss. Greensboro, NC: ERIC Clearinghouse on Counseling and Student Services. (ERIC Document Reproduction Services No. ED 315 708).
Source: ERIC Clearinghouse on Counseling and Student Services
January 2002
Page last modified or reviewed on January 24, 2014

Ah, food! A great way to forget your troubles and be happy - or so it seems. Actually, good nutrition can be a way of reducing stress, but, unfortunately, stress has the ability to alter your eating patterns for the worse. Many times the result is more stress, not less.

The prevalence of overweight and obesity has reached epidemic proportions in the United States . Numerous federal and private studies and reports over the last thirty years consistently indicate that the proportion of adults who are overweight or obese has grown by about 20%. What happened in the past few decades? How did the girth of our nation manage to reach these epidemic proportions? The math is pretty simple: too many calories in and not enough out. In other words, you get fat when you eat too much and don't exercise enough.

Unfortunately, it's not a black and white picture of exercise and diet. There are a lot of gray areas. You must also look at the behavior and environmental factors contributing to overweight and obesity. There must be other things at play here - like STRESS! Look at the average American's lifestyle: less personal or family time and more extracurricular activities than ever to keep you moving at a frantic pace, even on weekends. There are long commutes, long work hours, less personal time, less time spent eating together around the family table (without the TV blaring) and more divorce and single parent households.

Stress has the ability to upset a balanced lifestyle by disrupting eating and exercising habits and altering schedules. When under stress, your eating habits may be affected in one of two ways: you will eat more or eat less than you need. Unfortunately, most people tend to eat more when stressed and more of the wrong kinds of foods. Common practices include skipping breakfast, eating snacks laden with sugar, fat and salt, and finding dinner at fast food restaurants. Add to that not exercising, smoking, not getting enough sleep, sitting for hours in front of the TV or computer...no wonder you are stressed!

Stress can trigger emotional eating cravings that have nothing to do with hunger. When the going gets tough, you may tend to crave comfort foods that you remember fondly from your youth. Comfort food preferences vary by person and by gender but the top picks include anything with salt, sugar and fat. Popular comfort foods include chocolate, pizza, cookies, pasta, ice cream, fresh bread and chips.

Maintaining good eating habits keeps your body healthy, helps control stress. How is your overall diet? Rate your eating habits on the following items by rating them 1 (never) to 5 (always):

• I eat a variety of foods.
• I understand portion sizes and eat all foods in moderate amounts.
• I choose lean meats and non-fat dairy products.
• I eat a variety of grains daily, especially whole grains.
• I eat 5 servings of fruits and vegetables each day.
• I eat a healthy breakfast each morning.
• I limit my consumption of fast foods.
• I limit my consumption of desserts and snack foods high in sugar and fat.
• I drink 8 glasses of water daily.
• I limit my consumption of sodas and caffeinated beverages.
• If I drink alcoholic beverages, I do so in moderation.
• I listen to my body's cues and eat when I am hungry.
• I maintain a healthy weight.
• I am physically active most days of the week.
• I avoid smoking and chewing tobacco.

How did you do? The higher your score is above 60, the more you are in tune with healthy habits for your body. Much below 45? The Stress Owner's Manual by Drs. Boenisch and Haney offers help!

Adapted from The Stress Owner's Manual: Meaning, Balance & Health in Your Life (2nd Ed.), by Ed Boenisch, PhD, and C. Michele Haney, PhD. Available at online and local bookstores or directly from Impact Publishers, Inc., PO Box 6016, Atascadero, CA 93423-6016,  or phone 1-800-246-7228.

Page modified or reviewed on January 24, 2014

The High Cost of Lying

When their child enters adolescence and begins pushing harder for freedom to grow, parents may begin to wonder: "Whatever happened to the truth?" Not that their little girl or boy was always honest, but their teenager seems more prone to lie both by commission (telling a deliberate falsehood) and by omission (not voluntarily disclosing all that parents need to know.)

Why do adolescents tend to lie more than children? Usually for freedom's sake - to escape punishment for misbehavior or to get to do what has been forbidden. To many teenagers, lying seems to be the easy way out of trouble or into adventure that has been disallowed. But lying is deceptive: what seems simpler at the moment proves complicated over time. The "easy way out" turns out to be extremely expensive, particularly for teenagers who have gotten so deeply into lying that they have a hard time getting out. To these young people, it can be helpful for parents to itemize the high cost of lying in order to encourage a return to truth. What to tell their errant teenager? Explain some of the costs that commonly accompany lying.

• Liars Injure Those They Love. Parents who are lied to can feel hurt because lies take advantage of their trust, can feel angry because of being deliberately misled, and can feel frightened because now they don't know what to believe and so feel out of control.
• Liars Are Double Punished. Lying is a gamble. If the teenager is not found out, then there is no punishment; but if the teenager is found out, he or she is punished twice - first for the offense, and second for lying about it.
• Liars Complicate Their Lives. Liars lead double lives, having to remember what they really did (the truth of what happened) and the lie they told about what they did (the falsehood they created.) Because they have two versions of reality manage, not one, telling lies proves twice as complicated as telling the truth.
• Liars Life in Fear. Concealing the truth, liars have to live in hiding, living in some degree of fear of being found out.
• Liars Feel Out of Control. Covering up one lie with another, pretty soon liars lose track of all the lies they've told and find it harder and harder to keep their story straight.
• Liars Lower Self-Esteem. Because they lack the courage to own up to the truth of their actions, liars live a coward's life; each time they run from the truth they run their self-esteem further down.
• Liars Are Lonely People. To stay away from questions and to keep from being found out, liars distance themselves from intimate others, becoming isolated in their own home, this protection increasingly cutting them off from open communication with those they love.
• Liars Fool Themselves. What begins as lying to others ends up as lying to them selves as liars lose track of what really happened and come to believe some of the untruths they have told.
• Liars Feel Guilty. Knowing they have abused and exploited the trust of those they love, liars end up feeling guilty for the damage they have caused.
• Liars Encourage Other People To Get Angry. Each time they are found out, liars must deal with people who usually resent being manipulated by lies.
• Liars Lose Credibility. The more lies are told and found out, the less easy it becomes for liars to be believed when they are actually telling the truth.
• Liars Lose Intimacy. With each lie that is told, estrangement builds in their relationships because there can be no intimacy without honesty, no trust without truth, no security without sincerity.
• Liars Are Relieved When They Are Found Out. Even though they may have to pay their dues for lying by accepting punishment, liars are relieved to be found out because now they can get back on an honest footing with people, and can stop living a fugitive life.
• Liars Victimize Themselves. Although people lied to feel mistreated, because of all the costs they pay, liars mistreat them selves even more.
• Liars Learn the Lesson of Lying. Liars learn that it is far easier to be the person lied to than to be the one who has been telling all the lies.

Given so many costs of lying, why then do children lie?

First, understand what lying is. Lying is the act of deliberately NOT telling the truth on order to gain illicit freedom or some other gain. It is commonly done in three ways.

• By falsifying information, swearing one truth when the contrary is true.
• By withholding information, presenting part of the truth, but not the whole.
• By manipulating information, misleading understanding by implying one truth to draw attention away from another.

There are many motivations behind why child children lie. A few of the more common causes are listed below:

• To get to do the forbidden
• To escape consequences of wrongdoing.
• To compensate for feeling inadequate by creating a false image to impress other people.
• To pretend that make-believe is real.
• To deny the reality of painful feelings or actual events.
• To avoid arousing emotional upset by being honest about what someone doesn't want to hear.
• To outsmart adults by fooling them with dishonesty.
• To self-protect from the threat of interpersonal harm.
• To cover up for friends' or loved ones' misdeeds.
• To conceal a source of guilt or shame.
• To create secrecy in order to enable addiction.

Whatever the reason, parents need to treat lying seriously. The quality of family life depends as much as anything on the quality of communication, and lying can erode that quality to devastating effect. There is no trust without truth. There is no intimacy without honesty. There is no safety without sincerity. And there is no such thing as a small lie because when parents overlook one lie they only encourage the telling of another.

So, when a child lies, what might parents helpfully do?

• Explain the high costs of lying so the child understands the risks that go with dishonesty.
• Declare how it feels to be lied to so the child understands how loving relationships can be emotionally affected.
• Apply some symbolic reparation - a task the child must do that he or she would not ordinarily have to do, to work the offense off.
• Insist on a full discussion about the lying - why it occurred, how the child could have chosen differently so that lying did not occur, what the child is going to do to prevent further lying, and what the child may need from the parents in order to make future truth telling easier to do.
• Declare that lying in the family will always be treated as a serious offense.
• Finally, parents need to declare that they intend to reinstate trust and the expectation of truth in order to give the child a chance to resume an honest relationship.

About the Author

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

© Carl Pickhardt, PhD, 2001-2002 Used with permission.

Page last modified or reviewed on January 24, 2014

The rationale to incorporate cultural competence into organizational policy are numerous. The National Center for Cultural Competence has identified six salient reasons for review:

1. To respond to current and projected demographic changes in the United States.

The make-up of the American population is changing as a result of immigration patterns and significant increases among racially, ethnically, culturally and linguistically diverse populations already residing in the United States. Health care organizations and programs, and federal, state and local governments must implement systemic change in order to meet the health needs of this diverse population.

Data from the 1990 census reveal that the number of persons who speak a language other than English at home rose by 43 percent to 28.3 million. Of these, nearly 45 percent indicate they have trouble speaking English.

The results of a March 1997 survey conducted by the Census Bureau reveal that one in every ten persons in the United States is foreign-born. Currently, the US foreign-born population comprises a larger segment than at any time in the past five decades. This trend is expected to continue.

The Children's Defense Fund predicts that early in the first decade following the year 2000, there will be 5.5 million more Latino children, 2.6 million more African-American children, 1.5 million more children of other races and 6.2 million fewer white, non-Latino children in the United States.

2. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds.

Nowhere are the divisions of race, ethnicity and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, there are continuing disparities in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaskan Natives and Pacific Islanders as compared with the US population as a whole. In recognition of these continuing disparities, the President of the United States has targeted six areas of health status and committed resources to address cancer, cardiovascular disease, infant mortality, diabetes, HIV/AIDS and child and adult immunizations aggressively.

3. To improve the quality of services and health outcomes.

Despite similarities, fundamental differences among people arise from nationality, ethnicity and culture, as well as from family background and individual experience. These differences affect the health beliefs and behaviors of both patients and providers have of each other.

The delivery of high-quality primary health care that is accessible, effective and cost efficient requires health care practitioners to have a deeper understanding of the socio-cultural background of patients, their families and the environments in which they live. Culturally competent primary health services facilitate clinical encounters with more favorable outcomes, enhance the potential for a more rewarding interpersonal experience and increase the satisfaction the individual receiving health care services.

Critical factors in the provision of culturally competent health care services include understanding of the:

• beliefs, values, traditions and practices of a culture;
• culturally-defined, health-related needs of individuals, families and communities;
• culturally-based belief systems of the etiology of illness and disease and those related to health and healing; and
• attitudes toward seeking help from health care providers.

In making a diagnosis, health care providers must understand the beliefs that shape a person's approach to health and illness. Knowledge of customs and healing traditions are indispensable to the design of treatment and interventions. Health care services must be received and accepted to be successful.

Increasingly, cultural knowledge and understanding are important to personnel responsible for quality assurance programs. In addition, those who design evaluation methodologies for continual program improvement must address hard questions about the relevance of health care interventions. Cultural competence will have to be inextricably linked to the definition of specific health outcomes and to an ongoing system of accountability that is committed to reducing the current health disparities among racial, ethnic and cultural populations.

4. To meet legislative, regulatory and accreditation mandates.

As both an enforcer of civil rights law and a major purchaser of health care services, the Federal government has a pivotal role in ensuring culturally competent health care services. Title VI of the Civil Rights Act of 1964 mandates that no person in the United States shall, on ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

Organizations and programs have multiple, competing responsibilities to comply with Federal, state and local regulations for the delivery of health services. The Bureau of Primary Health Care, in its Policy Information Notice 98-23 (8/17/98), acknowledges that: "Health centers serve culturally and linguistically diverse communities and many serve multiple cultures within one center. Although race and ethnicity are often thought to be dominant elements of culture, health centers should embrace a broader definition to include language, gender, socioeconomic status, housing status and regional differences. Organizational behavior, practices, attitudes and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served. Health centers should develop systems that ensure participation of the diverse cultures in their community, including participation of persons with limited English-speaking ability, in programs offered by the health center. Health centers should also hire culturally and linguistically appropriate staff."

The Maternal and Child Health Bureau, through its program efforts related to state accountability and Healthy People Year 2000/2010 Objectives includes an emphasis on cultural competency as an integral component of health service delivery. The National Health Promotion and Disease Prevention Objectives emphasize cultural competence as an integral component of the delivery of health and nutrition services.

State and Federal agencies increasingly rely on private accreditation entities to set standards and monitor compliance with these standards. Both the Joint Commission on the Accreditation of Healthcare Organizations, which accredits hospitals and other health care institutions, and the National Committee for Quality Assurance, which accredits managed care organizations and behavioral health managed care organizations, support standards that require cultural and linguistic competence in health care.

5. To gain a competitive edge in the market place.

The provision of publicly financed health care services is rapidly being delegated to the private sector. Issues of concern in the current health care environment include the marketing of health services and the cost-effectiveness of health care delivery. The potential for improved services lies in state managed-care contracts that can increase retention and access to care, expand recruitment and increase the satisfaction of individuals seeking health care services.

To reach these outcomes, managed care plans must incorporate culturally competent policies, structures and practices to provide services for people from diverse ethnic, racial, cultural and linguistic backgrounds.

6. To decrease the likelihood of liability/malpractice claims.

Lack of awareness about cultural differences may result in liability under tort principles in several ways. For example, providers may discover that they are liable for damages as a result of treatment in the absence of informed consent. Also, health care organizations and programs face potential claims that their failure to understand health beliefs, practices and behavior on the part of providers or patients breaches professional standards of care. In some states, failure to follow instructions because they conflict with values and beliefs may raise a presumption of negligence on the part of the provider.

The ability to communicate well with patients has been shown to be effective in reducing the likelihood of malpractice claims. A 1994 study appearing in the journal of the American Medical Association indicates that the patients of physicians who are frequently sued had the most complaints about communication. Physicians who had never been sued were likely to be described as concerned, accessible and willing to communicate. When physicians treat patients with respect, listen to them, give them information and keep communication lines open, therapeutic relationships are enhanced and medical personnel reduce their risk of being sued for malpractice.

Effective communication between providers and patients may be even more challenging when there are cultural and linguistic barriers. Health care organizations and programs must address linguistic competence--insuring for accurate communication of information in languages other than English.

References used to prepare this document:

A Vision for America's Future: An Agenda for the 1990s." (policy statement). Washington, D.C., Children's Defense Fund (1990).

"Health Care Rx: Access For All." (chart book). Washington, D.C., U.S. Department of Health and Human Services, 1998.

"Poor Communication With Patients Can Get You Sued." Physicians Risk Management Update, vol. 4(1), Physicians Insurance Exchange, 1995.

"The Initiative To Eliminate Racial and Ethnic Disparities in Health." (policy statement). Washington, D.C., U.S. Department of Health and Human Services, 1998.

The HIV/AIDS Epidemic in the United States, 1997-1998. (fact sheet). Atlanta, GA., Centers for Disease Control and Prevention, 1998.

Cross, T., Bazron, B., Dennis, K., and Isaacs, M. "Towards A Culturally Competent System of Care," vol. 1, Washington, D.C., National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center, 1989.

Goode, T. "The Cultural Competence Continuum." Training and Technical Assistance Resource Manual, (paper presented at conference on Culturally Competent Services and Systems: Implications for Children With Special Health Needs). Rio Grande, Puerto Rico, 1998.

Like, R. "Treating and Managing the Care of Diverse Patient Populations: Challenges for Training and Practice." (paper presented at national conference on Quality Health Care for Culturally Diverse Populations: Provider and Community Collaboration in a Competitive Marketplace.) New Brunswick, N.J., Center for Healthy Families and Cultural Diversity, Robert Wood Johnson Medical School, 1998.

Mason, J. "Rationale for Cultural Competence in Health and Human Services," Training and Technical Assistance Resource Manual, (paper presented at national conference on Culturally Competent Services and Systems: Implications for Children With Special Health Needs.) Rio Grande, Puerto Rico, 1998.

Source: National Center for Cultural Competence

Page modified or reviewed on January 24, 2014