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It is difficult to know how to talk to children about divorce. However, research has shown that talking to children about the divorce is helpful for them. Explaining about divorce helps them to make some sense of what is happening in the family. By talking to children, adults can help them understand tension between parents, a parent moving out of the house, or the unhappiness and anger of a parent. It is common for children to think that somehow they are responsible for things going wrong. It can be reassuring to tell them that parents were having problems and that it was not the child's fault.

Children need some time to adjust to the idea of divorce. They may have many questions about what divorce means.

• Will they see the parents?
• Will they live in the same house or go to the same school?
• Will they see their friends?
• Who will take care of them?
• Can parents divorce the children or stop loving them, too?
• Would the parents have stayed together if the children had been "good?"

Explaining the divorce to the children can give answers to some of these questions. The explanations can also help children with questions that they may not even know how to ask.

When you as a provider talk to children about divorce, you should take the lead from the parents. Check with parents to find out what they have said to the children. This can help you support the parents and avoid confusing the child. You can give information that will be consistent with what the child has already been told.

Remember that divorce is confusing for children. When you first talk with them, include only the most important and immediate issues. Children need to hear that their basic needs will be met. They need to hear that someone will still fix breakfast in the morning, read books with them, and tuck them in bed at night. Children also need to know that their relationship with BOTH parents will continue, if possible. This is why it is very important to have discussions with parents about what you can tell the children. You will need to ask parents whether the children will have contact with both parents. Find out from the parents what will be the same or different in the child's life now. This will help you decide what to tell the children.

Here are some suggestions that may help in explaining divorce to children:

• Talk with the parents before you talk with the children. Take the parent's lead.
• Give information that is consistent with what parents have already told the child.
• Keep the explanations simple.
• Keep the explanations appropriate to the child's age and development.
• Focus on the immediate concerns of the child.
• Avoid blaming either parent.
• Avoid talking about details. Use general statements. These statements can be very helpful:
  • "Mom and Dad have decided they would be happier living in different homes."
  • "Daddy and Mommy have decided not to live together in the same house."
  • "Daddy and Mommy will not be married anymore. They will be divorced. I know you are sorry this has to be the way, but Mommy and Daddy think this is best for everyone."
• It is best to avoid saying, "Daddy and Mommy don't love one another anymore." Children often hear that they are loved.
• If parents talk about not loving each other anymore, a child may fear that he will also lose the parents' love if he misbehaves.
• Listen to the child's questions. Find out what she already knows. Take the lead from the child.
• Be prepared for children to ask the same questions again and again.
• Avoid giving false hopes that the parents may get back together.
• Keep telling the children that the divorce is not their fault.

What to Explain and How

• Explain that children are not responsible for the divorce

Tell children that the divorce is not their fault. Many children who are 4 or 5 or older believe that the divorce is the result of something that they did. For example, some children may think that parents are divorcing because the child misbehaved or received bad grades in school. Children need to be told again and again that they are not responsible for the divorce.

• Explain that the divorce is permanent

Make it very clear to children that the parents will not be getting back together. Children need to hear that they cannot rescue or restore the marriage. At some ages, children may also make up stories about their parents getting back together. It is okay to pretend, but explain that the parents are really separated. This can help the children move on and accept other changes that may come into their lives.

• Explain that the parents love them, and the parents' love for them will not change

Help children understand that the love shared between a parent and a child is special. It is different from the love shared between a husband and wife. Husbands and wives might get divorced, but parents are always parents. Children need to know that the love parents have for them will last.

• Help children deal with the balancing act of relating to two divorced parents

Help children understand that it will be confusing to deal with their two parents. It may be hard to love both of them at once when the parents don't love each other. Tell children that it's OK to love both Mom and Dad. Children should not feel they have to take sides or worry about losing the love of either parent. After a divorce, children's loyalty may become split. They may feel caught between the parents. Though the parents may never ask a child to take sides, children can still feel they have to choose one parent over the other. Many children take a long time to work through feelings of split loyalty. This is a normal process of children adjusting to their parents' divorce. As a childcare provider, you may be able to help the child deal with these issues. You may say, "Sometimes you may feel guilty for missing Dad while you are staying with Mom. Sometimes you may feel you have to choose whether you love Mom more or Dad more. It's OK to feel all these confused feelings and thoughts. Many children feel that way when their parents get divorced."

• Give children a chance to express their feelings, and name the different feelings they have

Sometimes younger children do not understand what they are feeling. You can help them learn about feelings by reading books to them about divorce. You can read books about feelings, too. You also can do activities that will help children understand feelings.

• Explain that they are not alone in the way they feel

Children can feel that they are the only ones who have these troubles. They may feel that their family is the only one that has ever gone through divorce. You can help children learn that divorce happens in many families. This can help the children feel less alone. If you have divorce in your family, you could share how you feel about it. For example, you may say, "I'm sorry that this is so sad for you. I can understand. I feel sad, too. I remember when my parents divorced..." Help children understand that they are not the only ones feeling sad or angry or relieved. You may help the child understand the parents by saying, "Mom and Dad are probably sad about the divorce too. I am sure they are sorry this had to happen to you. They may wish that your family did not have to separate just like you do. How do you think they are feeling? What do you think makes them happy and what makes them sad about the divorce?" This can teach children that everyone has some of the same feelings. It is OK to have feelings and express them to others.

• Help children understand that their feelings may be different from the parents' or siblings' feelings

Let children know that members of the family may not always share the same feelings about the divorce. Explain to the children that it's all right to feel differently from the parents and from brothers and sisters. A child may not understand why Mom or Dad is relieved about the divorce while the child is sad and hurt. Explain to the child that people have different feelings and that feelings are neither right nor wrong. For example, you could say, "I know you are hurt that Daddy left home. But he and Mom may have been unhappy for a long time. This divorce may be a relief for them. But it is OK for you to be sad." Tell them that feelings may be different on different days, too.

• Check with the children often about their fears and concerns

Watch for signs that show how the children are feeling. Let them talk about their fears, concerns, and feelings about the divorce or about what is happening at home now. Give children time to think about the divorce and the changes it may have brought about. Don't expect to have only one big discussion. Talk as many times as the issue may come up. Children will want to talk about different issues as time goes on. Take children's questions and concerns seriously and LISTEN to what they say. As one older child said, "this is gonna affect the rest of my life and I don't know if they just don't realize that, or don't care, or what, but I don't feel like I'm being heard." Children need to know that adults (caregivers, parents, and concerned others) want to help them deal with the divorce and are concerned about how the divorce is affecting them.

Explaining Divorce to Other Children

As a provider, you may need to explain the divorce of one child's parents to other children in your care. These children may wonder why Juan lives with his father on the weekend and with his mother during the weekdays. They may ask questions about why Jenny's father never comes to the childcare to pick her up, or what Jenny means when she says that her parents are divorced. You can help them understand by using simple statements. The other children do not need to know details, but they do need some information. This will also make it easier for the child in the divorcing family. She will not need to explain if you take care of it.

As a childcare provider, you can help children in your setting understand divorce and treat the children whose parents have divorced in a kind way. Sometimes the other children may ask the child in the divorcing family many questions. Sometimes they are curious. Other times they may make fun of the child or tease her. These reactions can make the child from the divorced family feel embarrassed, hurt, or ashamed. It is important to watch for these reactions and to try to avoid them from the beginning. Give a simple explanation to the children about divorce. Talk about it in a natural tone of voice. You can make divorce a normal thing. When children have answers, they will usually go on to other topics and stop questioning a specific child.

There are some words that you could use that will fit almost all divorce situations. You could say, "Jason's Mom and Dad were not happy living together. They have decided that it is best if they live in separate houses. Adults go through what they call a divorce when they decide to live separately like this and are not married any more. Even though Jason's Mom and Dad are not married, they love Jason very much, and they will always be his Mom and Dad."

Sometimes a childcare setting will include more than one child whose parents have divorced. If that is true in your childcare, those other children can be very helpful. They can show that divorce does not need to be a secret, and they can help the child realize that she is not alone. The children may help each other by sharing their experiences.

Some children may be afraid that their own parents will also divorce. This may be difficult to answer. You may not know if there are problems in the families. But you may be able to help the children with that question. You can answer, "Sometimes when parents are not getting along together, they decide to divorce. But not all parents make this decision. Most parents stay together, even though they might argue sometimes. Others may divorce. But even if they decide to divorce, both parents will love their children." You can also tell the children to ask their parents this question. Parents are in the best position to reassure the child that they are not getting a divorce. It may be helpful to let parents know if children ask about whether their parents will divorce. You can tell them you asked the child to talk to them. This way they can be prepared with an answer for their child.

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
by Nithyakala Karuppaswamy and Judith Myers-Walls, PhD, CFLE

Page last modified or reviewed by AH on May 22, 2012

Most experts agree that open communication contributes to good relationships. However, one of the most awkward things about sharing strong feelings with another person is getting started.

When you want to express your feelings, you first need to get the attention of the other person involved. You have to pick a time and place when the other person really wants to hear your feelings. Then you need an effective way of getting your message across. These factors are especially important when the other person contributed to the way you feel - as in the case of anger in a relationship.

For openers, you could say something like:

• I'd like to talk with you about... Is this a good time?
• I've got a problem - could I share it with you?
• Something's bothering me. May I talk with you about it?
• I need your help on...
• I'm really feeling (hurt, scared, angry, sad, worried, excited...)

Realize that when you share your feelings, many people will want to help you feel better or give you some advice. If this is okay with you, fine. If not - if you just want to ventilate - state what you want: I really would like you to hear my feelings. I'm not looking for advice or comfort, just a chance to ventilate; is that okay with you? If the person slips into the role of advisor or comforter, just gently remind him or her of what you want: I'd really like to tell you more about what I'm feeling.

In other words, you're probably going to have to train others to listen to your feelings. Few of us get that kind of education as we're growing up.

Now that you have the other person's attention, you're ready to get on to the important stuff. The path ahead is fraught with "road hazards" that can interfere with effective communication! Assume that you want to share your feelings about a behavior that you find bothersome; let's start with what not to do. Some ways to express feelings are not helpful because they deliberately threaten people. One of the most common of these ineffective approaches is called the "you-message."

You-messages attack and blame another person for your feelings: "You make me so mad!" "It's your fault I'm depressed." "You hurt my feelings." "You're stressing me out." Such messages set the state for counterattack. A person on the receiving end of a you-message often gets defensive - he or she doesn't really hear your feelings.

When you send a you-message, you place the responsibility for your feelings on someone else. It's as if you were saying, "If it weren't for you, I wouldn't feel this way." While it may be true that the other person is a stimulus for you to feel a certain way, your feelings are still your choice.

Now, on to what to do: I-messages. This is a style that gets your point across without attacking the other person.

I-messages are responsibility-taking messages. They don't attack, blame, ridicule or criticize - they simply share how you feel: "I feel hurt when you talk to me that way. It seems as if you don't care." "When I'm pushed, I feel stressed. I can't meet your time schedule and I think you expect me to."

I-messages have to do with letting another know he's affecting you, whether you feel good or feel as if he's stepping on your toes. The person's behavior may be violating your rights or contributing to your emotional state.

Some people find it easier to form I-messages if they use a formula:

• When... (state the behavior that you find bothersome) "When we make plans to spend time together and you change your mind at the last minute..."

• I feel... (state how you feel about the consequences the person's behavior has for you) "I feel disappointed..."

• Because... (state the consequences of the person's behavior for you) "...because I was looking forward to our time together."

When you send an I-message, you're being respectful to the other person as well as yourself. You communicate an intent to stimulate cooperation, not rebellion or compliance.

Adapted from How You Feel Is Up to You: The Power of Emotional Choice (2nd Ed.), by Gary D. McKay, PhD, and Don Dinkmeyer, Sr., PhD. Available at online and local bookstores or directly from Impact Publishers, Inc., PO Box 6016, Atascadero, CA 93423-6016, http://www.bibliotherapy.com/ or phone 1-800-246-7228.

Reviewed by athealth on February 4, 2014.

When we hear the terms "discipline" and "father," there appears to be a natural connection, but often with negative overtones. The idea of a father as one who punishes or is an authoritarian figure runs deep in our culture. Yet, fathers have much more to offer than only helping their children learn self- control and social rules, and their role involves much more than punishment.

Discipline is one of those familiar words that carry different meanings. To many people, discipline simply implies the setting of firm rules and limits and administering punishments for breaking those rules. But, in fact, the meaning is more complex. The word discipline is based on the Latin word "discipulus," which means "a pupil," or more accurately, "one who is learning." Thus, the ancient origins of discipline are based on the notion of a reciprocal process of teaching and learning.

This notion is included in the modern definition of discipline. According to the American Heritage Dictionary (2000), the verb "to discipline" is defined as: 1. to train by instruction and practice, especially to teach self-control to. 2. to teach to obey rules or accept authority. See Synonyms at teach. 3. to punish in order to gain control of, enforce obedience. See Synonyms at punish.

When discipline refers to training and teaching specific behaviors of selfcontrol and moral development, this becomes a tall order for all parents, yet one that has historically been embraced by fathers. Indeed, prior to the 1900s in western culture, it was assumed that fathers more than mothers were responsible for the development of their children's moral behavior and self control. Men were expected to take on the critical teaching role. How can today's fathers provide discipline, in the sense of teaching and training their children? When does discipline start, and what form does it take?

Why Discipline is Important

The association between child-rearing practices and children's development of self-control has been well documented in research. Studies indicate that the quality of parental care is critical in the first year of life. Parents who are responsive, stimulating, and encouraging with their babies are laying the foundation for the development of self-control. During this first year, babies learn whether or not their signals, such as cries when hungry, or cold, are understood, and if their needs are met. A successful interaction involves a parent reacting to a baby's message and behaving responsively and leads to more successful social interactions (Parke & Sawin 1976). In the second year, when children begin walking and exploring on their own, it is important for parents to set limits for the child's safety and provide guidelines for acceptable behavior. Parents begin to think more and more about how and when to discipline their toddlers who are increasingly asserting their independence and autonomy which are necessary, normal aspects of early development.

The temperament of each young child affects each parent's approach to discipline. Research shows that fussy, active, or difficult toddlers often drive their parents to be more restrictive and more punitive (Patterson 1980). A cycle of negative interactions is set in motion; misbehavior is followed by punishment; punishment is followed by increasing, accelerating patterns of misbehavior. The father's role in these family interactions involves both the support of the mother and direct interactions with the child. Both research studies and parents themselves report that the hard-to-manage children are more compliant and agreeable with their fathers than with their mothers. Also, when the father is present in the room or nearby, children are much more compliant with their mothers (Patterson 1980; Lytton 1980). Research also indicates that when problems spiral out of control, sometimes fathers step in with harsh, direct punishment to get the situation back under control, which, unfortunately, can precipitate a cycle of punishment and misbehavior (DeKlyen 1998). Thus, poorly modulated behavior in a toddler or preschool child can overwhelm the mother or father, as well as split the parents into disagreement as they argue on how to manage the child. When parents disagree on behavior management, there is little improvement in the child.

The first positive strategy is to help the parents agree on how to handle some specific parenting issues. For example, they might come up with a plan to follow at bedtime, including specific ways to talk with the child. In this way, consistency is built up in the home environment. Calm, consistent behavior by adults is the model for teaching self-control in the child. The concept of discipline as teaching a set of behaviors to the child "not just punishment" becomes a reality only when there is consistency. A consistent plan on handling bedtime tantrums carried out by the mother and father can go a long way toward establishing a general pattern of discipline and the development of self-control.

Sidebar: Strategies for disciplining kids who have ADHD. Be clear about the expectations; consistent; patient; rather than just saying "no," explain (preferably show) the child what positive behavior you expect; reward positive behavior with attention.

Research emphasizes the important role of fathers in helping children to learn the standards of behavior for their group and to develop the capacity of self-regulation (Lamb 1987). When fathers are absent, curtail, or ignore their child-rearing responsibilities, there are implications throughout the family system. Mothers are likely to feel unsupported, abandoned, angry, and resentful. The resulting tension exacerbates the child's challenging behaviors. Lack of parental involvement by the father leaves the mother as the sole unsupported teacher of social skills and deprives the child of another role model. When fathers do not participate in child rearing, the results can be heightened intensity and duration of mother-child conflict and problems in discipline (Campbell 2002).

Playing with Children

The role of fathers for all children, not just those with challenging behaviors, is unique and important. As Lamb (1998) has indicated, the father is typically the one who engages in physical rough and tumble play with children. In the course of active play, children may test limits. Whether the activity involves tickling, wrestling or splashing in the pool, paying attention and stopping when needed are important lessons to be learned. Thus, discipline and learning self-control can start with play.

Fathers tend to be more active in their play, helping their children to be first in a race, catch the ball the most times, throw the farthest, jump the farthest, and leap into the water. While mothers are sometimes exasperated at fathers who get their sons and daughters excited, energized, and otherwise "all worked up," play has purpose. It tests limits and boundaries generally pushed less often by mothers. The children have to learn how to play without hurting someone else or getting hurt themselves, and how to direct their energy.

Constructive play is something both fathers and mothers can enjoy. Whether building with blocks to construct a road or a family's house, or "cooking" with play food and utensils, children enjoy the process of creating and constructing, then starting all over again. One of the most valuable interactions a father can have is getting down on the floor each day for 15 minutes and playing with his child - playing, commenting, and giving undivided attention.

Talking to Children

How parents speak greatly influences how often children comply with directions. While individuals certainly differ, the research is fairly consistent that mothers tend to explain more to their children, while fathers tend to use fewer words in all interactions. Fathers are often more tactile and physical, while mothers are typically more verbal and didactic (Parke 1996). Let's look at the task of giving a child the command to get ready to go to bed. Many mothers assume that if the child really understands why it is time for bed, they will be more likely to go to bed. For example, a mother might say, "Go to bed now because you have a busy day tomorrow," and follow it with a long explanation about how the body needs to rest, the child looks tired, and so on. However, the child, may lose track of the direction "go to bed" in the midst of all the other words.

On the other hand, some parents, more often fathers, tend to be a bit more direct, but often without the explanation. A very direct, "Go to bed now" appears harsh and may elicit some negative emotions from the child. An effective middle ground would be a brief explanation, followed by a clear command:" It's past your bedtime, you've had a busy day and have a lot to do tomorrow. It's time to go to bed." Repeating the direction (go to bed) at the end of the verbal exchange helps bring it to the child's attention.

Consequences: Positive and Negative

Consistently positive or negative responses to a child's behavior will change how often the child will respond the same way. Most child behavior is shaped by hundreds of daily back-and-forth interactions with the world around them, not by any single event or response. In short, parents need to do what they say, and to be consistent. If parents promise to do things and do them each time they promise, their children will trust and expect them to follow through. If a parent promises to play after dinner, and does, the child may eat more neatly and quickly. If a parent promises to take away a privilege because the child has broken a rule, the parent needs to do it so the child follows the rule next time. Promises are critically important when fathers do not live with their children and visits are arranged. Promised visits, phone calls and activities must occur, or the child learns not to trust the father, or other adults for that matter.

When positive and negative consequences are used to shape behavior, large, lavish one-time rewards of an expensive toy or video game, or harsh intense punishments such as being spanked severely or sent to one's room for hours, are not as effective as the little rewards of adult attention and time, or consistent brief mild punishments. For most children between the ages of two and six, a brief "Time Out" of sitting away quietly, not isolated, but not being paid attention is the most effective mild punishment. "Time Out" allows both parent and child to cool down, and the withdrawal of adult attention functions to reduce the problem behavior in the future. Other brief logical consequences include a short loss of privilege. For example if two children fight over a toy or what to watch on TV, and are unable to problem-solve, a parent might put the toy away temporarily or turn off the TV for a half hour. The key here is to follow through, calmly and consistently. Of course, these are also opportune times to teach children strategies for working out their disagreements.

Conclusion

When fathers understand that disciplining their child is an opportunity to teach by words and actions, they will have an important role in helping their children learn appropriate behavior and self-control. Engaging in fun play, conversation, and the use of fair consequences are times when discipline can be used in positive, nurturing ways.

Valuing Discipline

The following points are taken from the 21st Century Exploring Parenting Program, a Head Start publication. In Session 7 of the program, values are defined as standards of right and wrong that guide behavior. Though most parents do not realize it, their values determine how and why they discipline their children. It is therefore important for parents to evaluate their own values and to understand that every time they discipline their children, they are teaching about values.

Discipline is better understood as guidance and teaching, not controlling and punishing. Over time, children will learn how to control themselves, but until they can, adults need to help them by setting appropriate limits and modeling correct behavior. Discipline is an all day - every day teaching and learning process. These points will help parents as they continue to guide their young children.

• Values are principles and standards that guide our behavior.
• The values that individual family members hold dear vary considerably.
• Parents want their children to accept their values.
• The words "discipline" and "disciple" come from the Latin word "discipulus" which means pupil or student - one who learns.
• Babies need to be loved, nurtured, and accepted as they are. Nothing they do can be called misbehavior.
• Toddlers need adults to make rules that keep them and others safe and protect the family's belongings. They need help in keeping these rules and controlling their behavior.
• Preschoolers still need help in regulating their behavior. They are ready for more explanations about why they must do some things and cannot do others.
• The more time you spend in positive interaction with your children, the more likely it is that they will accept your values and want to please you.
• The combination of positive time together and discipline usually works better than discipline alone.

References

1. Campbell, S.B. 2002. Behavior Problems in Preschool Children: Clinical and Developmental Issues. Second Edition. New York: Guilford Press.DeKlyen, M., Speltz, M.L., Greenberg, M.T. 1998. Fathering and early onset conduct problems: Positive and negative parenting, father-son attachment, and marital conflict. Clinical Child and Family Psychology Review, 1, 3-22.
2. Lamb, M.E. 1987. The father's role: Cross-cultural perspectives. Hillsdale, N.J.: Erlbaum.
3. Lamb, M.E. 1998. Nonparental child care: Context, quality, correlates, and consequences. In W. Damon (Series Ed.) & I. Sigel & A.K. Renninger (Vol. Eds) Handbook of Child Psychology: Volume 4. Child psychology in practice. San Francisco, CA: John Wiley.
4. Lytton, H. 1980. Parent-Child interaction: The socialization process observed in twins and singleton families. New York: Plenum Press.
5. Mash E.J. & Johnston, C. 1983. Sibling interactions of hyperactive and normal children and their relationship to reports of maternal stress and self-esteem. Journal of Clinical Child Psychology. 12, 91-99.
6. Parke, R.D. 1996. Fatherhood. Cambridge: Harvard University Press.
7. Parke, R.D. & Sawin, D.B. 1976. The father's role in infancy: A Reevaluation. The Family Coordinator. 25, 365-371.
8. Pickett, J. et al (Eds). 2000. American Heritage Dictionary. Boston: Houghton Mifflin.
9. W. Douglas Tynan is a clinical psychologist and Director of the Disruptive Behavior Clinic at A. I. duPont Hospital for Children, Wilmington, DE

Head Start Bulletin
Issue No. 77
by W. Douglas Tynan
Last Modified: 06/17/04

Reviewed by athealth on February 4, 2014.

• What is FAS?
• How common is FAS?
• What are the characteristics of children with FAS?
• How can we prevent FAS?

What is FAS?

Prenatal exposure to alcohol can cause a spectrum of disorders. One of the most severe effects of drinking during pregnancy is fetal alcohol syndrome (FAS). FAS is one of the leading known preventable causes of mental retardation and birth defects. If a woman drinks alcohol during her pregnancy, her baby can be born with FAS, a lifelong, physically and mentally disabling condition. FAS is characterized by (1) abnormal facial features, (2) growth deficiencies, and (3) central nervous system (CNS) problems. People with FAS may have problems with learning, memory, attention span, communication, vision, and/or hearing. These problems often lead to difficulties in school and problems getting along with others. FAS is a permanent condition. It affects every aspect of an individual's life and the lives of his or her family. However, FAS is 100% preventable - if a woman does not drink alcohol while she is pregnant.

Many terms have been used to describe children who have some, but not all, of the clinical signs of FAS. Three terms are fetal alcohol effects (FAE), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD). FAE has been used to describe children who have all of the diagnostic features of FAS, but at mild or less severe levels. In 1996, the Institute of Medicine (IOM) replaced FAE with the terms ARND and ARBD. Those with ARND may have functional or mental problems linked to prenatal alcohol exposure. These include behavioral and/or cognitive abnormalities. Examples are learning difficulties, poor school performance, and poor impulse control. They may have difficulties with mathematical skills, memory, attention, and/or judgment. Those with ARBD may have problems with the heart, kidneys, bones, and/or hearing.

How common is FAS?

The reported rates of FAS vary widely. These different rates depend on the population studied and the surveillance methods used. CDC studies show FAS rates ranging from 0.2 to 1.5 per 1,000 live births in different areas of the United States. Other prenatal alcohol-related conditions, such as alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) are believed to occur approximately three times as often as FAS.

What are the characteristics of children with FAS?

FAS is the severe end of a spectrum of effects that can occur when a woman drinks during pregnancy. Fetal death is the most extreme outcome. FAS is a disorder characterized by abnormal facial features, and growth and central nervous system (CNS) problems. If a pregnant woman drinks alcohol but her child does not have all of the symptoms of FAS, it is possible that her child has an alcohol-related neurodevelopmental disorder (ARND). Children with ARND do not have full FAS, but may demonstrate learning and behavioral problems caused by prenatal exposure to alcohol. If you think a child may have FAS or other alcohol-related effects, contact a doctor. Children with FAS or ARND may have the following characteristics or exhibit the following behaviors:

• small for gestational age or small in stature in relation to peers;
• facial abnormalities such as small eye openings;
• poor coordination;
• hyperactive behavior;
• learning disabilities;
• developmental disabilities (e.g., speech and language delays);
• mental retardation or low IQ;
• problems with daily living;
• poor reasoning and judgment skills;
• sleep and sucking disturbances in infancy.

Children with FAS are at risk for psychiatric problems, criminal behavior, unemployment, and incomplete education. These secondary conditions are problems that an individual is not born with, but might acquire as a result of FAS. These conditions can be very serious, yet there are protective factors that have been found to help individuals with these problems. For example, a child who is diagnosed early in life can be placed in appropriate educational classes and given access to social services that can help the child and his or her family. Children with FAS who receive special education are more likely to achieve their developmental and educational potential. In addition, children with FAS need a loving, nurturing, and stable home life in order to avoid disruptions, transient lifestyles, or harmful relationships. Children with FAS who live in abusive or unstable households or become involved in youth violence are much more likely to develop secondary conditions than children with FAS who have not had such negative experiences.

CDC is working to identify ways to help individuals with FAS and their families lessen or prevent secondary conditions. CDC is currently sponsoring (1) a five-site collaborative effort investigating effective strategies for intervening with children with FAS and/or alcohol-related neurodevelopmental disorder (ARND) and their families and (2) the development of educational curricula about FAS and ARND targeting parents, school staff, health and social service providers, law enforcement officials and medical and allied health students and professionals.

How can we prevent FAS?

FAS and other prenatal alcohol-related conditions are completely preventable - if a woman does not drink alcohol while she is pregnant or could become pregnant. If a woman is drinking during pregnancy, it is never too late for her to stop. The sooner a woman stops drinking, the better it will be for both her baby and herself. If a woman is not able to stop drinking, she should contact her physician, local Alcoholics Anonymous or local alcohol treatment center, if needed. The Substance Abuse and Mental Health Services Administration (SAMHSA) has a Substance Abuse Treatment Facility locator. This locator helps people find drug and alcohol treatment programs in their area. If a woman is sexually active and not using an effective form of birth control, she should not drink alcohol. She could be pregnant and not know it for several weeks or more.

Mothers are not the only ones who can prevent FAS. The father's role is also important in helping the woman abstain from drinking alcohol during pregnancy. He can encourage her abstinence from alcohol by avoiding social situations that involve drinking and by abstaining from alcohol himself. Significant others, family members, schools, health and social service organizations, and communities alike can help prevent FAS through education and intervention.

To reduce prenatal alcohol exposure, prevention efforts should target not only pregnant women who are currently drinking, but also women who could become pregnant, are drinking at high-risk levels, and are engaging in unprotected sex.

National Center on Birth Defects and Developmental Disabilities
Last Updated Wednesday, April 13, 2005

What Is Fibromyalgia?

Fibromyalgia syndrome is a common and chronic disorder characterized by widespread muscle pain, fatigue, and multiple tender points. The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia). Tender points are specific places on the body?on the neck, shoulders, back, hips, and upper and lower extremities?where people with fibromyalgia feel pain in response to slight pressure.

Although fibromyalgia is often considered an arthritisrelated condition, it is not truly a form of arthritis (a disease of the joints) because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person's ability to carry on daily activities. Also like arthritis, fibromyalgia is considered a rheumatic condition.

You may wonder what exactly rheumatic means. Even physicians do not always agree on whether a disease is considered rheumatic. If you look up the word in the dictionary, you'll find it comes from the Greek word rheum, which means flux?not an explanation that gives you a better understanding. In medicine, however, the term rheumatic means a medical condition that impairs the joints and/or soft tissues and causes chronic pain.

In addition to pain and fatigue, people who have fibromyalgia may experience:

• sleep disturbances,
• morning stiffness,
• headaches,
• irritable bowel syndrome,
• painful menstrual periods,
• numbness or tingling of the extremities,
• restless legs syndrome,
• temperature sensitivity,
• cognitive/memory problems (sometimes referred to as "fibro fog"), or
• a variety of other symptoms.

Fibromyalgia is a syndrome rather than a disease. Unlike a disease, which is a medical condition with a specific cause or causes and recognizable signs and symptoms, a syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

Who Gets Fibromyalgia?

According to a paper published by the American College of Rheumatology (ACR), fibromyalgia affects 3 to 6 million - or as many as one in 50 - Americans. For unknown reasons, between 80 and 90 percent of those diagnosed with fibromyalgia are women; however, men and children also can be affected. Most people are diagnosed during middle age, although the symptoms often become present earlier in life.

People with certain rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus (commonly called lupus), or ankylosing spondylitis (spinal arthritis) may be more likely to have fibromyalgia, too.

Several studies indicate that women who have a family member with fibromyalgia are more likely to have fibromyalgia themselves, but the exact reason for this - whether it be hereditary or caused by environmental factors or both - is unknown. One study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is trying to identify if certain genes predispose some people to fibromyalgia. (See What Are Researchers Learning About Fibromyalgia?)

What Causes Fibromyalgia?

The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. People with rheumatoid arthritis and other autoimmune diseases, such as lupus, are particularly likely to develop fibromyalgia. For others, fibromyalgia seems to occur spontaneously.

Many researchers are examining other causes, including problems with how the central nervous system (the brain and spinal cord) processes pain.

Some scientists speculate that a person's genes may regulate the way his or her body processes painful stimuli. According to this theory, people with fibromyalgia may have a gene or genes that cause them to react strongly to stimuli that most people would not perceive as painful. However, those genes?if they, in fact, exist?have not been identified.

How Is Fibromyalgia Diagnosed?

Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with many other conditions. Therefore, doctors often have to rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia; standard laboratory tests fail to reveal a physiologic reason for pain. Because there is no generally accepted, objective test for fibromyalgia, some doctors unfortunately may conclude a patient's pain is not real, or they may tell the patient there is little they can do.

A doctor familiar with fibromyalgia, however, can make a diagnosis based on two criteria established by the ACR: a history of widespread pain lasting more than 3 months and the presence of tender points. Pain is considered to be widespread when it affects all four quadrants of the body; that is, you must have pain in both your right and left sides as well as above and below the waist to be diagnosed with fibromyalgia. The ACR also has designated 18 sites on the body as possible tender points. For a fibromyalgia diagnosis, a person must have 11 or more tender points. (See illustration on page 5.) One of these predesignated sites is considered a true tender point only if the person feels pain upon the application of 4 kilograms of pressure to the site. People who have fibromyalgia certainly may feel pain at other sites, too, but those 18 standard possible sites on the body are the criteria used for classification.

How Is Fibromyalgia Treated?

Fibromyalgia can be difficult to treat. Not all doctors are familiar with fibromyalgia and its treatment, so it is important to find a doctor who is. Many family physicians, general internists, or rheumatologists (doctors who specialize in arthritis and other conditions that affect the joints or soft tissues) can treat fibromyalgia.

Fibromyalgia treatment often requires a team approach, with your doctor, a physical therapist, possibly other health professionals, and most importantly, yourself, all playing an active role. It can be hard to assemble this team, and you may struggle to find the right professionals to treat you. When you do, however, the combined expertise of these various professionals can help you improve your quality of life.

You may find several members of the treatment team you need at a clinic. There are pain clinics that specialize in pain and rheumatology clinics that specialize in arthritis and other rheumatic diseases, including fibromyalgia.

At present, there are no medications approved by the U.S. Food and Drug Administration (FDA) for treating fibromyalgia, although a few such drugs are in development. Doctors treat fibromyalgia with a variety of medications developed and approved for other purposes.

Following are some of the most commonly used categories of drugs for fibromyalgia:

Analgesics

Analgesics are painkillers. They range from over-the-counter acetaminophen (Tylenol*) to prescription medicines, such as tramadol (Ultram), and even stronger narcotic preparations. For a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

As their name implies, nonsteroidal anti-inflammatory drugs, including aspirin, ibuprofen (Advil, Motrin), and naproxen sodium (Anaprox, Aleve), are used to treat inflammation. Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain. The drugs work by inhibiting substances in the body called prostaglandins, which play a role in pain and inflammation. These medications, some of which are available without a prescription, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

Antidepressants

Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine (which was formerly called adrenaline). Low levels of these chemicals are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia, described below.

• Tricyclic antidepressants - When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body's natural pain-killing substances called endorphins.Tricyclic antidepressants have been around for almost half a century. Some examples of tricyclic medications used to treat fibromyalgia include amitriptyline hydrochloride (Elavil, Endep), cyclobenzaprine (Cycloflex, Flexeril, Flexiban), doxepin (Adapin, Sinequan), and nortriptyline (Aventyl, Pamelor). Both amitriptyline and cyclobenzaprine have been proved useful for the treatment of fibromyalgia.
• Selective serotonin reuptake inhibitors - If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a newer type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia. Studies have shown that a combination therapy of the tricyclic amitriptyline and the SSRI fluoxetine resulted in greater improvements in the study participants' fibromyalgia symptoms than either drug alone.
• Mixed reuptake inhibitors - Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors. Examples of these medications include venlafaxine (Effexor) and nefazadone (Serzone). Researchers are actively studying the efficacy of these newer medications in treating fibromyalgia.

Benzodiazepines

Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies. Benzodiazepines include clonazepam (Klonopin) and diazepam (Valium).

Other medications

In addition to the previously described general categories of drugs, doctors may prescribe others, depending on a person's specific symptoms or fibromyalgia-related conditions. For example, in recent years, two medications? tegaserod (Zelnorm) and alosetron (Lotronex) - have been approved by the FDA for the treatment of irritable bowel syndrome. Gabapentin (Neurontin) currently is being studied as a treatment for fibromyalgia. (See What Are Researchers Learning About Fibromyalgia?.) Other symptom-specific medications include sleep medications, muscle relaxants, and headache remedies.

People with fibromyalgia also may benefit from a combination of physical and occupational therapy, from learning pain-management and coping techniques, and from properly balancing rest and activity.

Complementary and alternative therapies

Many people with fibromyalgia also report varying degrees of success with complementary and alternative therapies, including massage, movement therapies (such as Pilates and the Feldenkrais method), chiropractic treatments, acupuncture, and various herbs and dietary supplements for different fibromyalgia symptoms. (For more information on complementary and alternative therapies, contact the National Center for Complementary and Alternative Medicine. See Where Can I Get More Information About Fibromyalgia?.)

Though some of these supplements are being studied for fibromyalgia, there is little, if any, scientific proof yet that they help. The FDA does not regulate the sale of dietary supplements, so information about side effects, the proper 12 dosage, and the amount of a preparation's active ingredient may not be well known. If you are using or would like to try a complementary or alternative therapy, you should first speak with your doctor, who may know more about the therapy's effectiveness, as well as whether it is safe to try in combination with your medications.

Will Fibromyalgia Get Better With Time?

Fibromyalgia is a chronic condition, meaning it lasts a long time - possibly a lifetime. However, it may comfort you to know that fibromyalgia is not a progressive disease. It is never fatal, and it won't cause damage to your joints, muscles, or internal organs. In many people, the condition does improve over time.

What Can I Do To Try To Feel Better?

Besides taking medicine prescribed by your doctor, there are many things you can do to minimize the impact of fibromyalgia on your life. These include:

• Getting enough sleep - Getting enough sleep and the right kind of sleep can help ease the pain and fatigue of fibromyalgia. (See Tips for Good Sleep.) Even so, many people with fibromyalgia have problems such as pain, restless legs syndrome, or brain-wave irregularities that interfere with restful sleep.
• Exercising - Though pain and fatigue may make exercise and daily activities difficult, it's crucial to be as physically active as possible. Research has repeatedly shown that regular exercise is one of the most effective treatments for fibromyalgia. People who have too much pain or fatigue to do vigorous exercise should begin with walking or other gentle exercise and build their endurance and intensity slowly. Although research has focused largely on the benefits of aerobic and flexibility exercises, a new NIAMS-supported study is examining the effects of adding strength training to the traditionally prescribed aerobic and flexibility exercises.
• Making changes at work - Most people with fibromyalgia continue to work, but they may have to make big changes to do so; for example, some people cut down the number of hours they work, switch to a less demanding job, or adapt a current job. If you face obstacles at work, such as an uncomfortable desk chair that leaves your back aching or difficulty lifting heavy boxes or files, your employer may make adaptations that will enable you to keep your job. An occupational therapist can help you design a more comfortable workstation or find more efficient and less painful ways to lift.If you are unable to work at all due to a medical condition, you may qualify for disability benefits through your employer or the Federal Government.Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) are the largest Federal programs providing financial assistance to people with disabilities. Though the medical requirements for eligibility are the same under the two programs, the way they are funded is different. SSDI is paid by Social Security taxes, and those who qualify for assistance receive benefits based on how much an employee has paid into the system; SSI is funded by general tax revenues, and those who qualify receive payments based on financial need. For information about the SSDI and SSI programs, contact the Social Security Administration. (See Where Can I Get More Information About Fibromyalgia?.)
• Eating well - Although some people with fibromyalgia report feeling better when they eat or avoid certain foods, no specific diet has been proven to influence fibromyalgia. Of course, it is important to have a healthy, balanced diet. Not only will proper nutrition give you more energy and make you generally feel better, it will also help you avoid other health problems.

Tips for Good SleepKeep regular sleep habits. Try to get to bed at the same time and get up at the same time every day?even on weekends and vacations.Avoid caffeine and alcohol in the late afternoon and evening. If consumed too close to bedtime, the caffeine in coffee, soft drinks, chocolate, and some medications can keep you from sleeping or sleeping soundly. Even though it can make you feel sleepy, drinking alcohol around bedtime also can disturb sleep. Time your exercise. Regular daytime exercise can improve nighttime sleep. But avoid exercising within 3 hours of bedtime, which actually can be stimulating, keeping you awake. Avoid daytime naps. Sleeping in the afternoon can interfere with nighttime sleep. If you feel you can't get by without a nap, set an alarm for 1 hour. When it goes off, get up and start moving. Reserve your bed for sleeping. Watching the late news, reading a suspense novel, or working on your laptop in bed can stimulate you, making it hard to sleep. Keep your bedroom dark, quiet, and cool. Avoid liquids and spicy meals before bed. Heartburn and latenight trips to the bathroom are not conducive to good sleep. Wind down before bed. Avoid working right up to bedtime. Do relaxing activities, such as listening to soft music or taking a warm bath, that get you ready to sleep. (An added benefit of the warm bath: It may soothe aching muscles.)

What Are Researchers Learning About Fibromyalgia?

The NIAMS sponsors research that will improve scientists' understanding of the specific problems that cause or 16 accompany fibromyalgia, in turn helping them develop better ways to diagnose, treat, and prevent this syndrome.

The research on fibromyalgia supported by NIAMS covers a broad spectrum, ranging from basic laboratory research to studies of medications and interventions designed to encourage behaviors that reduce pain and change behaviors that worsen or perpetuate pain.

Following are descriptions of some of the promising research now being conducted:

• Understanding pain - Because research suggests that fibromyalgia is caused by a problem in how the body processes pain - or more precisely, a hypersensitivity to stimuli that normally are not painful - several NIAMS-supported researchers are focusing on ways the body processes pain to better understand why people with fibromyalgia have increased pain sensitivity.Previous research has shown that people with fibromyalgia have reduced blood flow to parts of the brain that normally help the body deal with pain. In one new NIAMS-funded study, researchers will be using imaging technology called positron emission tomography (PET) to compare blood flow in the brains of women who have have fibromyalgia with those who do not. In both groups, researchers will study changes in blood flow that occur in response to painful stimuli.Researchers speculate that female reproductive hormones may be involved in the increased sensitivity to pain characteristic of fibromyalgia. New research will examine the role of sex hormones in pain sensitivity, in reaction to stress, and in symptom perception at various points in the menstrual cycles of women with fibromyalgia and of women without it. The results from studying these groups of women will be compared with results from studies of the same factors in men without fibromyalgia over an equivalent period of time.Another line of NIAMS-funded research involves developing a rodent model of fibromyalgia pain. Rodent models, which use mice or rats that researchers cause to develop symptoms similar to fibromyalgia in humans, could provide the basis for future research into this complex condition.
• Understanding stress - Medical evidence suggests that a problem or problems in the way the body responds to physical and/or emotional stress may trigger or worsen the symptoms of any illness, including fibromyalgia. Researchers funded by NIAMS are trying to uncover and understand these problems by examining chemical interactions between the nervous system and the endocrine (hormonal) system. Scientists know that people whose bodies make inadequate amounts of the hormone cortisol experience many of the same symptoms as people with fibromyalgia, so they also are exploring if there is a link between the regulation of the adrenal glands, which produce cortisol, and fibromyalgia.Another NIAMS-funded study suggests that exercise improves the body's response to stress by enhancing the function of the pituitary and adrenal glands. The hormones produced by these two endocrine glands are essential to regulating sleep and emotions, as well as processing pain.
• Improving sleep - Researchers supported by NIAMS are investigating ways to improve sleep for people with fibromyalgia whose sleep problems persist despite treatment with medications. One team has observed that fibromyalgia patients with persistent sleep problems share characteristics with people who have insomnia, such as having erratic sleep and wake schedules and spending too much time in bed. This team is testing whether strategies developed to help insomnia patients will also help people with fibromyalgia achieve deep sleep, which eases pain and fatigue. Preliminary results show that sleep education, which teaches good sleep habits, and cognitive behavioral therapy, which includes sleep education and a regimen to correct poor habits and improper sleep schedules, both reduce insomnia.
• Looking for the family connection - Because fibromyalgia appears to run in families, one group of NIAMS-supported researchers is working to identify whether a gene or genes predispose people to the condition.Another team is trying to determine if fibromyalgia is more common in people with other conditions, such as serious mood disorders, that tend to run in families. Specifically, the group is studying the prevalence of psychiatric disorders and arthritis and related disorders in people with fibromyalgia and their first-degree relatives (parents, children, sisters, brothers) as compared to people with rheumatoid arthritis and their relatives. The group is exploring whether clusters of conditions exist in families, which might shed light on shared common risk factors or disease processes.
• Studying and targeting treatments - NIAMS recently funded its first study of a drug treatment for fibromyalgia. The study will measure the effectiveness of gabapentin, an anticonvulsant medication, in reducing symptoms of fibromyalgia. Gabapentin has been found to relieve chronic pain caused by nervous system disorders, and it was recently approved by the FDA for the treatment of persistent, severe pain that can follow an episode of shingles.Scientists recognize that people with fibromyalgia often fall into distinct subgroups that adapt to and cope with their symptoms differently. They also realize that these subgroups may respond to treatments differently. One NIAMS-funded team of researchers has divided people with fibromyalgia into three groups based on how they cope with the condition. Relative to other chronic pain patients, those in the first group have higher levels of pain and report more interference in their life due to pain. They also have higher levels of emotional distress, and feel less control over their lives and are less active. The second group reports receiving less support from others, higher levels of negative responses from significant others, and lower levels of supportive responses from significant others. Those in the third group are considered adaptive copers; they have less pain, report less interference in their lives due to pain, and have less emotional distress. Members of this last group feel more control over their lives and are more active. On the premise that the better you understand the subgroups, the better you can tailor treatments to fit them, the researchers now are trying to design and test different programs for each group, combining physical therapy, interpersonal skills training, and supportive counseling.

Where Can I Get More Information About Fibromyalgia?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
[email protected]
http://www.niams.nih.gov

National Center for Complementary and Alternative Medicine
National Institutes of Health
PO Box 7923
Gaithersburg, MD 20898-7923
Phone: 888-644-6226 (free of charge)
TTY: 866-464-3615 (free of charge)
Fax: 866-464-3616 (free of charge)
[email protected]
http://www.nccam.nih.gov

Social Security Administration
Office of Public Inquiries
Windsor Park Building
6401 Security Boulevard
Baltimore, MD 21235
Phone: 800-772-1213 (free of charge)
TTY: 800-325-0778 (free of charge)
http://www.ssa.gov/disability

American College of Rheumatology/Association of Rheumatology Health Professionals
1800 Century Place, Suite 250
Atlanta, GA 30345-4300
Phone: 404-633-3777
Fax: 404-633-1870
http://www.rheumatology.org

Advocates for Fibromyalgia Funding, Treatment, Education, and Research
PO Box 768
Libertyville, IL 60048-0766
Phone: 847-362-7807
Fax: 847-680-3922
[email protected]
http://www.affter.org

Fibromyalgia Network
PO Box 31750
Tucson, AZ 85751-1750
Phone: 800-853-2929 (free of charge)

Home

National Fibromyalgia Association
2200 N. Glassell Street, Suite "A"
Orange, CA 92865
Phone: 714-921-0150

Home New

National Fibromyalgia Partnership
PO Box 160
Linden, VA 22642-0160
Phone: 866-725-4404 (free of charge)
Fax: 866-666-2727 (free of charge)
[email protected]
http://www.fmpartnership.org

Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or
800-283-7800 (free of charge) or call your local chapter
(To find your local chapter, check your phone directory or visit the foundation's Web site.)
http://www.arthritis.org

Key Words

Adrenal glands - A pair of endocrine glands located on the surface of the kidneys. The adrenal glands produce corticosteroid hormones such as cortisol, aldosterone, and the reproductive hormones.

Arthritis - Literally means joint inflammation, but is often used to indicate a group of more than 100 rheumatic diseases. These diseases affect not only the joints but also other connective tissues of the body, including important supporting structures, such as muscles, tendons, and ligaments, as well as the protective covering of internal organs.

Analgesic - A medication or treatment that relieves pain.

Connective tissue - The supporting framework of the body and its internal organs.

Chronic disease - An illness that lasts for a long time, often a lifetime.

Cortisol - A hormone produced by the adrenal cortex, important for normal carbohydrate metabolism and for a healthy response to stress.

Fibrous capsule - A tough wrapping of tendons and ligaments that surrounds the joint.

Fibromyalgia - A chronic syndrome that causes pain and stiffness throughout the connective tissues that support and move the bones and joints. Pain and localized tender points occur in the muscles, particularly those that support the neck, spine, shoulders, and hip. The disorder includes widespread pain, fatigue, and sleep disturbances.

Inflammation - A characteristic reaction of tissues to injury or disease. It is marked by four signs: swelling, redness, heat, and pain. Inflammation is not a symptom of fibromyalgia.

Joint - A junction where two bones meet. Most joints are composed of cartilage, joint space, fibrous capsule, synovium, and ligaments.

Ligaments - Bands of cordlike tissue that connect bone to bone.

Muscle - A structure composed of bundles of specialized cells that, when stimulated by nerve impulses, contract and produce movement.

Nonsteroidal anti-inflammatory drugs (NSAIDs) - A group of drugs, such as aspirin and aspirin-like drugs, used to reduce inflammation that causes joint pain, stiffness, and swelling.

Pituitary gland - A pea-sized gland attached beneath the hypothalamus at the base of the skull that secretes many hormones essential to bodily functioning. The secretion of pituitary hormones is regulated by chemicals produced in the hypothalamus.

Sleep disorder - A disorder in which a person has difficulty achieving restful, restorative sleep. In addition to other symptoms, people with fibromyalgia usually have a sleep disorder.

Tender points - Specific places on the body where a person with fibromyalgia feels pain in response to slight pressure.

Tendons - Fibrous cords that connect muscle to bone.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of Deborah Ader, PhD, NIAMS, NIH; Karen Amour and Lynne Matallana, National Fibromyalgia Association, Orange, CA; Michele L. Boutaugh, MPH, Arthritis Foundation, Atlanta, GA; Daniel Clauw, MD, and Leslie Crofford, MD, University of Michigan, Ann Arbor; and Tamara Liller, National Fibromyalgia Partnership, Linden, VA, in the preparation of this booklet.

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Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 04-5326
2004

Reviewed by athealth on February 4, 2014.

From 50 yards away, you see the animal approaching. Silently it watches you as it slinks ever so much closer with each padded step. Stay calm, you tell yourself. There's nothing to fear.

But suddenly, panic seizes you in a death grip, squeezing the breath out of you and turning your knees to Jell-O. Your heart starts slam-dancing inside your chest, your mouth turns to cotton, and your palms are so sweaty you'd swear they'd sprung a leak. You'd escape this terrifying confrontation, if only you could make your legs work!

Just what is this wild and dangerous animal making you hyperventilate and turning your legs to rubber? A man-eating tiger, hungry for a meal? A lioness bent on protecting her cubs? Guess again. That's Tabby, your neighbor's ordinary house cat, sauntering your way. Ridiculous, right? How can anyone experience so much fear at the sight of such an innocuous animal? If you're one of the thousands who suffer from galeophobia--the fear of cats--or any one of hundreds of other phobias, sheer panic at the appearance of everyday objects, situations or feelings is a regular occurrence.

Irrational Fears

A phobia is an intense, unrealistic fear of an object, an event, or a feeling. An estimated 18 percent of the U.S. adult population suffers from some kind of phobia, and a person can develop a phobia of anything--elevators, clocks, mushrooms, closed spaces, open spaces. Exposure to these trigger the rapid breathing, pounding heartbeat, and sweaty palms of panic.

There are three defined types of phobias:

• Specific or simple phobias - fear of an object or situation, such as spiders, heights or flying
• Social phobias - fear of embarrassment or humiliation in social settings
• Agoraphobia - fear of being away from a safe place

No one knows for sure how phobias develop. Often, there is no explanation for the fear. In many cases, though, a person can readily identify an event or trauma--such as being chased by a dog--that triggered the phobia. What puzzles experts is why some people who experience such an event develop a phobia and others do not. Many psychologists believe the cause lies in a combination of genetic predisposition mixed with environmental and social causes.

Phobic disorders are classified as part of the group of anxiety disorders, which includes panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Several drugs regulated by the Food and Drug Administration are now being used to treat phobias and other anxiety disorders.

Dogs, Snakes, Dentists . . .

A person can develop a specific phobia of anything, but in most cases the phobia is shared by many and has a name. Animal phobias--cynophobia (dogs), equinophobia (horses), zoophobia (all animals)--are common. So are arachnophobia (spiders) and ophidiophobia (snakes). And, of course, there's the fear of flying (pterygophobia), heights (acrophobia), and confined spaces (claustrophobia).

"One of the most common phobias is the fear of dentists [odontiatophobia]," says Sheryl Jackson, Ph.D., a clinical psychologist and associate professor at the University of Alabama at Birmingham. "People who suffer with this phobia will literally let their teeth rot out because they are afraid to go to a dentist."

Jackson says that most specific phobias do not cause a serious disruption in a person's life, and, consequently, sufferers do not seek professional help. Instead, they find ways to avoid whatever it is that triggers their panic, or they simply endure the distress felt when they encounter it. Some may also consult their physicians, requesting medication to help them through a situation, such as an unavoidable plane trip for someone who is phobic about flying.

Drugs prescribed for these short-term situations include benzodiazepine anti-anxiety agents. These medications include two approved for treating anxiety disorders: Xanax (alprazolam) and Valium (diazepam). Beta blockers such as Inderal (propranolol) and Tenormin (atenolol), approved for controlling high blood pressure and some heart problems, have been acknowledged, partly on the basis of controlled trials, to be helpful in certain situations in which anxiety interferes with performance, such as public speaking.

Some phobias cause significant problems that require long-term professional help. "People usually seek treatment when their phobia interferes in their lives--the person who turns down promotions because he knows public speaking will be required, someone who must travel frequently but who is afraid of flying, or a woman who wants to have children but who has a fear of pain or blood. These are the people who seek long-term treatment," says Jackson.

While anti-anxiety medication sometimes may be used initially, systematic desensitization may also be an effective initial approach. Jackson explains that this nondrug treatment works on the theory that the more a person is exposed to the object of his phobia, the less fear that object generates.

First, the patient and therapist establish a hierarchy of feared situations, from the least to the most feared. For someone who fears elevators, for example, stepping onto the elevator causes a certain level of anxiety; going up one flight causes another level of anxiety. With each additional flight the anxiety increases until it becomes intolerable.

Therapy begins with the patient and therapist practicing the least fearful event, riding out the anxiety until the physiological symptoms subside. This step is repeated until the anxiety level is acceptable. Then the person progresses to the next step in the hierarchy. Each successive step is repeated until the physical reactions and anxious mood decrease to the point where the person can step onto an elevator and ride to the top floor without panicking.

Everyone's Looking at Me!

Social phobia is a complex disorder, characterized by the fear of being criticized or humiliated in social situations. There are two types of social phobias: circumscribed, which relates to a specific situation such as "stage fright," and generalized social phobia, which involves fear of a variety of social situations.

People suffering from social phobia fear the scrutiny of others. They tend to be highly sensitive to criticism, and often interpret the actions of others in social gatherings as an attempt to humiliate them. They are afraid to enter into conversations for fear of saying something foolish, and may agonize for hours or days later over things they did say.

"I always believed that everybody else knew the secret to enjoying themselves in social situations, that I was the only one who was so afraid," says Lorraine from Birmingham, AL, who asked that her last name not be used. "For a long time, I avoided as many situations as possible, even talking on the telephone. After a while, the loneliness and boredom would overwhelm me, and I would try again. I wanted to have fun, but I never really enjoyed myself because of the anxiety I felt. I always believed that others were looking at me and judging me."

Many people with social phobia are so sensitive to the scrutiny of others that they avoid eating or drinking in public, using public restrooms, or signing a check in the presence of another. Social phobia may often be associated with depression or alcohol abuse.

Neurotransmitter-receptor abnormalities in the brain are suspected to play a part in the development of social phobias. Neurotransmitters are substances such as norepinephrine, dopamine and serotonin that are released in the brain. The substance then either excites or inhibits a target cell. Disorders in the physiology of these neurotransmitters are thought to be the cause of a variety of psychiatric illnesses.

Negative social experiences, such as being rejected by peers or suffering some type of embarrassment in public, and poor social skills also seem to be factors, and social phobia may be related to low self-esteem, lack of assertiveness, and feelings of inferiority.

Treatment can include cognitive-behavior therapy and medications, though no drug is approved specifically for social phobia. In addition to the anti-anxiety drugs and beta-blockers, medications may include the monoamine oxidase (MAO) inhibitor antidepressants Nardil (phenelzine) and Parnate (tranylcypromine), and serotonin specific reuptake inhibitors (SSRIs) such as Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), and Luvox (fluvoxamine). Of the latter four drugs, Prozac, Zoloft and Paxil are approved for depression; Prozac, Paxil, Luvox, and Zoloft are approved for obsessive-compulsive disorder; and Paxil is approved for panic disorder.

Chris Sletten, Ph.D., a clinical psychologist and behavioral medicine specialist at the Mayo Clinic, says the use of SSRIs with behavior therapy is becoming more popular in the treatment of social phobia. Because there are fewer side effects associated with these drugs and a very low addiction potential, practitioners are more comfortable prescribing them. Plus, the antidepressant action of these drugs is helpful in treating patients who suffer from depression in addition to social phobia, he says.

"My therapist prescribed Prozac, and it has been an absolute godsend for me," Lorraine says. "After only a couple of months taking it, those voices in my head, the ones that always assured me that everyone was judging me--and finding me lacking--just seemed to shut up. I didn't feel high or drugged in any way. I felt like I always thought a "normal" person would feel. It's not a complete cure, of course. I still feel anxiety in social situations. But I don't avoid them as much. In fact, I actually pick up the phone now and ask friends to dinner, and I can relax enough to have fun. It's a whole new life for me."

The Wide Open Spaces

Agoraphobia comes from Greek, meaning literally "fear of the marketplace," but it usually is defined as a fear of open spaces. Sletten says it stems more from the fear of being someplace where you will not be able to escape. It is closely identified with panic disorder, and in many cases, agoraphobia is directly related to the fear of experiencing a panic attack in public.

A person with panic disorder suffers sudden bouts of panic for no apparent reason. These attacks can occur anywhere at any time. One minute everything is fine, the next the person is engulfed by a feeling of terror. The heart races, breathing comes in gasps, and the entire body trembles. The attack may last only minutes, but its memory is etched indelibly in the brain, and the anticipation of another causes almost as much terror as the attack itself.

People who suffer agoraphobia avoid places and situations where they feel escape would be difficult in case an attack occurs. This could be anywhere--the grocery store, a shopping mall, the office. As the fear of an attack increases, the agoraphobic's world narrows to only a few places where he or she feels safe. In the most severe cases, this is limited to the home.

Agoraphobia is the most disabling of all the phobias, and treatment is difficult because there are so many associated fears--the fear of crowds, of elevators, of traffic. As with social phobias, treatment involves behavioral therapy combined with anti-anxiety or antidepressant medications, or both. Paxil has received FDA approval for use in treating panic disorders with or without agoraphobia, and at press time, Zoloft was being considered for this additional use.

"The most important thing for people with phobias to remember," says Sletten, "is that phobic disorders do respond well to treatment. It's not something they have to continue to suffer with."

FDA Consumer Magazine
Date: March 1997
By Lynne L. Hall

Reviewed by athealth on February 4, 2014.

Rationale for Filial Therapy

Many children do not have their need for emotional nurturing met (Landreth, 2002). Communication gaps between parents and children may exist because many parents are unaware of their children's emotional needs and lack the skills necessary to interact effectively with them on an emotional level (Landreth, 2002). Children communicate through play (Axline, 1969; Landreth, 2002). It is their innate language. By teaching parents the language of play, and how to use play therapeutically, the communication gap between parent and child can be closed (Guerney, Guerney, & Andronico, 1999; Landreth, 2002).

Filial therapy is an alternative method for treating emotionally disturbed children in which the parent is used as an ally in the therapeutic process. The parent becomes the child's primary therapeutic agent (Guerney, et. al. 1999; Landreth, 2000; VanFleet, 2000). Parental involvement in a child's developmental process facilitates the parent's motivation to continue sessions and thus tends to eliminate the typical parental resistance that is encountered when the parent is not involved in the child's therapy.

Guerney (1969) reported the primary source of maladjustment, for many children living with their families, could logically be traced to interpersonal relationships within the family. Filial therapy teaches the parent a new way of interacting with their child, thus improving the parent-child relationship (Guerney, et. al. 1999; Landreth, 2000; VanFleet, 2000). Additionally, filial therapy provides focused attention to the child from a person who holds emotional significance to the child, thus encouraging anxieties learned by the parental influence to be unlearned, and provides opportunities for miscommunications to be clarified to the child by the parent (Guerney, et. al. 1999; Sweeney, 1997).

This approach is based on the therapeutic nature of play and the parent's ability to learn to assume the therapeutic role required of them for a short period of time under special conditions (Johnson, 1995). The parent's new role permits a child to explore personal struggles by breaking previous patterns of parent-child interaction. It also is expected that parents will generalize new patterns to life outside of the play sessions (Guerney, Guerney, Andronico, 1966).

The Process of Filial Therapy

Filial Therapy is an approach used by play therapists to train parents to be therapeutic agents with their own children. Parents are taught basic child-centered play therapy principles and skills, including reflective listening, recognizing and responding to children's feelings, therapeutic limit setting, building children's self-esteem, and structuring required weekly play sessions with their children using selected toys (Landreth, 2002). The therapist typically utilizes didactic instruction, demonstration play sessions, role-playing, group discussion, required at-home laboratory play sessions, videotapes, and supervision in a supportive atmosphere to educate parents. Parents learn how to create a warm, nonjudgmental, unconditionally accepting, genuine, and understanding environment in which their child feels safe to explore the parent-child relationship and themselves, including fears, desires, feelings, and struggles (Guerney, et. al., 1999; Landreth, 2002).

After a parent passes an initial screening to ensure the parent and child are appropriate candidates, the parent is placed in a parenting training group, composed of six to eight parents of children ages three to ten, that can include mothers, fathers, and spouses from other families. The parents are given opportunities to express their parenting and play session concerns and struggles with the group at weekly meetings. As the therapist deems necessary, filial therapy training groups last six to eighteen months (Guerney, 1969; Van Fleet, 2000).

Initial training's are spent exploring the parent child relationship and establishing a commitment from the parents. The parent's role is modeled after that of a child-centered play therapist (Guerney, et. al. 1999). Training emphasizes skills such as reflection of feeling, tracking, limit setting, and increasing parental sensitivity to their children. Once an adequate skill level is met, parents begin in home play sessions with their child. Parents are given a defined therapeutic role to play for a defined period of time and provided with feedback and supervision by the therapist and fellow parents in the following weekly training group (Guerney, 1969).

During assigned play sessions, the parent is expected to be empathic, understanding and accepting, while allowing the child to direct the play. It is critical that the parent be able to convey this understanding and acceptance to their child (Guerney, et. al. 1969). These conditions facilitate both the child's expression of emotion and a new perceptual awareness from the parent about their child (VanFleet, 1994).

When children are permitted to express themselves without losing status in the eyes of their parents the children's anxiety diminishes. The child feels validated and valued, and is able to master difficulties and feelings rather than try to distort and deny them. As these changes occur and the child experiences the parent in a new manner, the child begins to understand his or her sense of worth. Frustrations and hostilities diminish as the communication gap is bridged (Guerney, et. al., 1999).

The parent learns to set limits on the child's behavior when needed. In order to ensure continued empathic understanding felt and conveyed by the parent, behavior is not permitted that results in the parent or child being physically harmed. While maintaining acceptance of the child's feelings and desires, the parent learns to facilitate the child's expression in socially appropriate manners rather than overt, disruptive, harmful means (VanFleet, 1995).

Sidebar: Strategies for disciplining kids who have ADHD. Be clear about the expectations; consistent; patient; rather than just saying "no," explain (preferably show) the child what positive behavior you expect; reward positive behavior with attention.

The consistency of the special playtime, the toys used, and the relationship between parent and child results in a change in perception of the parent by the child. As the parents continue weekly at home play sessions they also attend supportive filial group meetings that explore techniques, the meaning of their child's play, and their personal emotional reactions to the sessions (Landreth, 2002). The therapist meets only with the parents and works in both a didactic and in a more traditional therapeutic role with the parental group to facilitate personal exploration and skill comprehension among parents. Both the home play sessions and the group sessions make unique contributions toward helping the parent-child relationship (Guerney, et.al., 1999).

Toys and Materials

The filial therapist facilitates the child's expression of a wide range of feelings by providing a wide range of toys. The playroom should communicate that all feelings are accepted(VanFleet, 1994). Items likely to direct a child's play, such as books or electronic toys, are avoided.

The availability of items such as bop bag, dart gun, and dinosaur, conveys a message to the child that anger and aggression are accepted. Inappropriate aggressive or harmful behaviors are redirected to acceptable outlets. Baby bottles, dolls, kitchen food and ware facilitate the expression of nurturance. A dollhouse and associated figures and furniture are often used in the expression of family issues (Landreth, 2002). The playroom should further include nondirective expressive media, such as craft and construction pieces, paint, crayons, markers, paper, clay or sand. These items encourage a variety of expression. The inclusion of a ring toss game or blocks and play money can facilitate the expression of mastery, competition, and cooperation themes. Other recommended items are puppets, a baby bottle, a bowl for water, container with water, small plastic soldiers or dinosaurs, Play-Doh(R), and a 6' piece of rope (Landreth, 2002). A toy should only be added to a playroom if it is safe for children, encourages the expression of feeling or themes, and allows for imagination or projective use (VanFleet, 1994). Functionality is priority. The toys do not need to be elaborate. "Toys and material should be selected, not collected," (Landreth, 2002, p. 133).

Filial Therapy Research and Results

Filial therapy is a philosophically-based process that has proven to be beneficial in a variety of settings, populations, and formats including but, not limited to: two-parent families, foster parents, single parents, incarcerated mothers, incarcerated fathers, parents of different nationalities, parents of mentally challenged children, parents of chronically ill children, parents of children demonstrating conduct problems, parents of children with learning difficulties, and non-offending parents of sexually abused children (Rennie & Landreth, 2000). Results from the aforementioned studies demonstrated improvement on a variety of variables including: parental empathy, parental stress, parental perception of positive changes in the family environment, parental self-esteem, parental perception of child adjustment, parental perception of child's behavioral problems, child self-concept, and changes in a child's play behavior (Rennie & Landreth, 2000).

Current and Future Trends in Filial Therapy

Originally filial therapy was developed as a long-term group approach limited to aid children age ten or younger (Guerney et. al., 1966). Since then, others have adopted the concepts and methods previously presented to intensified or individualized formats. Some examples are: VanFleet's (1994) depiction of filial therapy as a beneficial modality in treating individual families; Guerney's (1990) instructions on utilizing filial tools with adolescents; and Landreth's (1991) 10-week intensified filial therapy model. Trends since have included further intensification with beneficial results in only five weeks of treatment (Rennie & Landreth, 2000).

Conclusion

Filial therapy is an empirically supported treatment medium for meeting the emotional needs of children and bridging the communication gap that is frequently present in today's parent-child relationship. The characteristics of this powerful intervention are ideal in that the parent-child relationship is improved, thus potentially producing life changing results in a brief length of time.

References

1. Axline, V. (1969). Play therapy. New York: Ballantine Books.
2. Guerney, B. G. Jr. (1969). Filial therapy: Description and rationale. In B. G. Jr. Guerney, (Ed), Psycho-therapeutic agents: New roles for nonprofessionals, parents and teachers (pp. 450-460). New York: Holt, Rinehart and Winston.
3. Guerney, B. G. Jr., Guerney, L., & Andronico, M. (1966, March). Filial therapy. Yale Scientific Magazine, 40, 6-14, 20.
4. Guerney, B. G. Jr., Guerney, L., & Andronico, M. (1999). Filial therapy. In C. Schaefer, (Ed), The therapeutic use of child's play (pp. 553-566). Northvale, NJ: Jason Aronson.
5. Guerney, L. F. (1990). Parenting adolescents: A supplement to parenting, a skills training program. Silver Spring, MD: Ideals
6. Johnson, L. (1995). Filial therapy: A bridge between individual child therapy and family therapy. Journal of Family Psychotherapy, 6(3), 55-70.
7. Landreth, G. L. (2002). Play therapy: The art of the relationship (2nd ed.). New York: Brunner Routledge.
8. Landreth, G.L. (1991). Play therapy: The art of the relationship. Muncie, IN: Accelerated Development.
9. Rennie, R. & Landreth, G. (2000). Effects of filial therapy on parent and child behaviors. International Journal of Play Therapy, 9(2), 19-37.
10. Sweeney, D. S. (1997). Counseling children through the world of play. Wheaton, IL: Tyndale House Publisher.
11. VanFleet, R. (1994). Filial therapy: Strengthening parent-child relationships through play. Practitioner's Resource Series. Harrisburg, PA: Family Enhancement and Play Therapy Center. Sarasota, FL: Professional Resource.
12. VanFleet, R. (2000). A parent's handbook of filial play therapy. Boiling Springs, PA: Play Therapy.

Source: ERIC Digest
ERIC Clearinghouse on Elementary and Early Childhood Education
December 2002
Author: Brandy Schumann, M.S., N.C.C., L.P.C.I., is a Doctoral Student of Counseling at the University of North Texas and a Doctoral Counseling Intern at the Child and Family Resource Clinic.

Reviewed by athealth on February 4, 2014.

Making a Commitment

You have taken the important first step on the path to physical fitness by seeking information. The next step is to decide that you are going to be physically fit. This pamphlet is designed to help you reach that decision and your goal.

The decision to carry out a physical fitness program cannot be taken lightly. It requires a lifelong commitment of time and effort. Exercise must become one of those things that you do without question, like bathing and brushing your teeth. Unless you are convinced of the benefits of fitness and the risks of unfitness, you will not succeed.

Patience is essential. Don't try to do too much too soon and don't quit before you have a chance to experience the rewards of improved fitness. You can't regain in a few days or weeks what you have lost in years of sedentary living, but you can get it back if your persevere. And the prize is worth the price.

In the following pages you will find the basic information you need to begin and maintain a personal physical fitness program. These guidelines are intended for the average healthy adult. It tells you what your goals should be and how often, how long and how hard you must exercise to achieve them. It also includes information that will make your workouts easier, safer and more satisfying. The rest is up to you.

Checking Your Health

If you're under 35 and in good health, you don't need to see a doctor before beginning an exercise program. But if you are over 35 and have been inactive for several years, you should consult your physician, who may or may not recommend a graded exercise test. Other conditions that indicate a need for medical clearance are:

• High blood pressure
• Heart trouble
• Family history of early stroke or heart attack deaths
• Frequent dizzy spells
• Extreme breathlessness after mild exertion
• Arthritis or other bone problems
• Severe muscular, ligament or tendon problems
• Other known or suspected disease

Vigorous exercise involves minimal health risks for persons in good health or those following a doctor's advice. Far greater risks are presented by habitual inactivity and obesity.

Defining Fitness

Physical fitness is to the human body what fine tuning is to an engine. It enables us to perform up to our potential. Fitness can be described as a condition that helps us look, feel and do our best. More specifically, it is:

"The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure- time activities and meeting emergency demands. It is the ability to endure, to bear up, to withstand stress, to carry on in circumstances where an unfit person could not continue, and is a major basis for good health and well-being."

Physical fitness involves the performance of the heart and lungs, and the muscles of the body. And, since what we do with our bodies also affects what we can do with our minds, fitness influences to some degree qualities such as mental alertness and emotional stability.

As you undertake your fitness program, it's important to remember that fitness is an individual quality that varies from person to person. It is influenced by age, sex, heredity, personal habits, exercise and eating practices. You can't do anything about the first three factors. However, it is within your power to change and improve the others where needed.

Knowing the Basics

Physical fitness is most easily understood by examining its components, or parts. There is widespread agreement that these four components are basic:

Cardiorespiratory Endurance - the ability to deliver oxygen and nutrients to tissues, and to remove wastes, over sustained periods of time. Long runs and swims are among the methods employed in measuring this component.

Muscular Strength - the ability of a muscle to exert force for a brief period of time. Upper-body strength, for example, can be measured by various weight-lifting exercises.

Muscular Endurance - the ability of a muscle, or a group of muscles, to sustain repeated contractions or to continue applying force against a fixed object. Pushups are often used to test endurance of arm and shoulder muscles.

Flexibility - the ability to move joints and use muscles through their full range of motion. The sit-and- reach test is a good measure of flexibility of the lower back and backs of the upper legs.

Body Composition - often considered a component of fitness. It refers to the makeup of the body in terms of lean mass (muscle, bone, vital tissue and organs) and fat mass. An optimal ratio of fat to lean mass is an indication of fitness, and the right types of exercises will help you decrease body fat and increase or maintain muscle mass.

A Workout Schedule

How often, how long and how hard you exercise, and what kinds of exercises you do should be determined by what you are trying to accomplish. Your goals, your present fitness level, age, health, skills, interest and convenience are among the factors you should consider. For example, an athlete training for high-level competition would follow a different program than a person whose goals are good health and the ability to meet work and recreational needs.

Your exercise program should include something from each of the four basic fitness components described previously. Each workout should begin with a warmup and end with a cooldown. As a general rule, space your workouts throughout the week and avoid consecutive days of hard exercise.

Here are the amounts of activity necessary for the average healthy person to maintain a minimum level of overall fitness. Included are some of the popular exercises for each category.

Warmup - 5-10 minutes of exercise such as walking, slow jogging, knee lifts, arm circles or trunk rotations. Low intensity movements that simulate movements to be used in the activity can also be included in the warmup.

Muscular Strength - a minimum of two 20-minute sessions per week that include exercises for all the major muscle groups. Lifting weights is the most effective way to increase strength.

Muscular Endurance - at least three 30-minute sessions each week that include exercises such as calisthenics, pushups, situps, pullups, and weight training for all the major muscle groups.

Cardiorespiratory Endurance - at least three 20-minute bouts of continuous aerobic (activity requiring oxygen) rhythmic exercise each week. Popular aerobic conditioning activities include brisk walking, jogging, swimming, cycling, rope-jumping, rowing, cross-country skiing, and some continuous action games like racquetball and handball.

Flexibility - 10-12 minutes of daily stretching exercises performed slowly, without a bouncing motion. This can be included after a warmup or during a cooldown.

Cool Down - a minimum of 5-10 minutes of slow walking, low-level exercise, combined with stretching.

A Matter of Principle

The keys to selecting the right kinds of exercises for developing and maintaining each of the basic components of fitness are found in these principles:

Specificity - pick the right kind of activities to affect each component. Strength training results in specific strength changes. Also, train for the specific activity you're interested in. For example, optimal swimming performance is best achieved when the muscles involved in swimming are trained for the movements required. It does not necessarily follow that a good runner is a good swimmer.

Overload - work hard enough, at levels that are vigorous and long enough to overload your body above its resting level, to bring about improvement.

Regularity - you can't hoard physical fitness. At least three balanced workouts a week are necessary to maintain a desirable level of fitness.

Progression - increase the intensity, frequency and/or duration of activity over periods of time in order to improve.

Some activities can be used to fulfill more than one of your basic exercise requirements. For example, in addition to increasing cardiorespiratory endurance, running builds muscular endurance in the legs, and swimming develops the arm, shoulder and chest muscles. If you select the proper activities, it is possible to fit parts of your muscular endurance workout into your cardiorespiratory workout and save time.

Measuring Your Heart Rate

Heart rate is widely accepted as a good method for measuring intensity during running, swimming, cycling, and other aerobic activities. Exercise that doesn't raise your heart rate to a certain level and keep it there for 20 minutes won't contribute significantly to cardiovascular fitness.

The heart rate you should maintain is called your target heart rate. There are several ways of arriving at this figure. One of the simplest is: maximum heart rate (220 - age) x 70%. Thus, the target heart rate for a 40 year-old would be 126.

Some methods for figuring the target rate take individual differences into consideration. Here is one of them:

• Subtract age from 220 to find maximum heart rate.
• Subtract resting heart rate (see below) from maximum heart rate to determine heart rate reserve.
• Take 70% of heart rate reserve to determine heart rate raise.
• Add heart rate raise to resting heart rate to find target rate.
• Resting heart rate should be determined by taking your pulse after sitting quietly for five minutes. When checking heart rate during a workout, take your pulse within five seconds after interrupting exercise because it starts to go down once you stop moving. Count pulse for 10 seconds and multiply by six to get the per-minute rate.

Controlling Your Weight

The key to weight control is keeping energy intake (food) and energy output (physical activity) in balance. When you consume only as many calories as your body needs, your weight will usually remain constant. If you take in more calories than your body needs, you will put on excess fat. If you expend more energy than you take in you will burn excess fat.

Exercise plays an important role in weight control by increasing energy output, calling on stored calories for extra fuel. Recent studies show that not only does exercise increase metabolism during a workout, but it causes your metabolism to stay increased for a period of time after exercising, allowing you to burn more calories.

How much exercise is needed to make a difference in your weight depends on the amount and type of activity, and on how much you eat. Aerobic exercise burns body fat. A medium-sized adult would have to walk more than 30 miles to burn up 3,500 calories, the equivalent of one pound of fat. Although that may seem like a lot, you don't have to walk the 30 miles all at once. Walking a mile a day for 30 days will achieve the same result, providing you don't increase your food intake to negate the effects of walking.

If you consume 100 calories a day more than your body needs, you will gain approximately 10 pounds in a year. You could take that weight off, or keep it off, by doing 30 minutes of moderate exercise daily. The combination of exercise and diet offers the most flexible and effective approach to weight control.

Since muscle tissue weighs more than fat tissue, and exercise develops muscle to a certain degree, your bathroom scale won't necessarily tell you whether or not you are fat. Well-muscled individuals, with relatively little body fat, invariably are overweight according to standard weight charts. If you are doing a regular program of strength training, your muscles will increase in weight, and possibly your overall weight will increase. Body composition is a better indicator of your condition than body weight.

Lack of physical activity causes muscles to get soft, and if food intake is not decreased, added body weight is almost always fat. Once-active people, who continue to eat as they always have after settling into sedentary lifestyles, tend to suffer from "creeping obesity."

Clothing

All exercise clothing should be loose-fitting to permit freedom of movement, and should make the wearer feel comfortable and self-assured.

As a general rule, you should wear lighter clothes than temperatures might indicate. Exercise generates great amounts of body heat. Light-colored clothing that reflects the sun's rays is cooler in the summer, and dark clothes are warmer in winter. When the weather is very cold, it's better to wear several layers of light clothing than one or two heavy layers. The extra layers help trap heat, and it?s easy to shed one of them if you become too warm.

In cold weather, and in hot, sunny weather, it's a good idea to wear something on your head. Wool watch or ski caps are recommended for winter wear, and some form of tennis or sailor's hat that provides shade and can be soaked in water is good for summer.

Never wear rubberized or plastic clothing, such garments interfere with the evaporation of perspiration and can cause body temperature to rise to dangerous levels.

The most important item of equipment for the runner is a pair of sturdy, properly-fitting running shoes. Training shoes with heavy, cushioned soles and arch supports are preferable to flimsy sneakers and light racing flats.

When to Exercise

The hour just before the evening meal is a popular time for exercise. The late afternoon workout provides a welcome change of pace at the end of the work day and helps dissolve the day's worries and tensions.

Another popular time to work out is early morning, before the work day begins. Advocates of the early start say it makes them more alert and energetic on the job.

Among the factors you should consider in developing your workout schedule are personal preference, job and family responsibilities, availability of exercise facilities and weather. It's important to schedule your workouts for a time when there is little chance that you will have to cancel or interrupt them because of other demands on your time.

You should not exercise strenuously during extremely hot, humid weather or within two hours after eating. Heat and/or digestion both make heavy demands on the circulatory system, and in combination with exercise can be an overtaxing double load.

Source: Guidelines for Personal Exercise Programs
Developed by the President's Council on Physical Fitness and Sports

Reviewed by athealth on February 4, 2014.

Studies have shown that these five steps will help you quit and quit for good. You have the best chances of quitting if you use them together:

1. Get ready.
2. Get support.
3. Learn new skills and behaviors.
4. Get medication and use it correctly.
5. Be prepared for relapse or difficult situations.

1. Get Ready

• Set a quit date.
• Change your environment.
• Get rid of ALL cigarettes and ashtrays in your home, car, and place of work.
• Don't let people smoke in your home.
• Review your past attempts to quit. Think about what worked and what did not.
• Once you quit, don't smoke -- NOT EVEN A PUFF!

2. Get Support and Encouragement

Studies have shown that you have a better chance of being successful if you have help. You can get support in many ways:

• Tell your family, friends, and coworkers that you are going to quit and want their support. Ask them not to smoke around you or leave cigarettes out.
• Talk to your health care provider (for example, doctor, dentist, nurse, pharmacist, psychologist, or smoking counselor).
• Get individual, group, or telephone counseling. The more counseling you have, the better your chances are of quitting. Programs are given at local hospitals and health centers. Call your local health department for information about programs in your area.

3. Learn New Skills and Behaviors

• Try to distract yourself from urges to smoke. Talk to someone, go for a walk, or get busy with a task.
• When you first try to quit, change your routine. Use a different route to work. Drink tea instead of coffee. Eat breakfast in a different place.
• Do something to reduce your stress. Take a hot bath, exercise, or read a book.
• Plan something enjoyable to do every day.
• Drink a lot of water and other fluids.

4. Get Medication and Use It Correctly

Medications can help you stop smoking and lessen the urge to smoke.

• The U.S. Food and Drug Administration (FDA) has approved five medications to help you quit smoking:
  • Bupropion SR -- Available by prescription.
  • Nicotine gum -- Available over-the-counter.
  • Nicotine inhaler -- Available by prescription.
  • Nicotine nasal spray -- Available by prescription.
  • Nicotine patch -- Available by prescription and over-the-counter.
• Ask your health care provider for advice and carefully read the information on the package.
• All of these medications will more or less double your chances of quitting and quitting for good.
• Everyone who is trying to quit may benefit from using a medication. If you are pregnant or trying to become pregnant, nursing, under age 18, smoking fewer than 10 cigarettes per day, or have a medical condition, talk to your doctor or other health care provider before taking medications.

5. Be Prepared for Relapse or Difficult Situations

Most relapses occur within the first 3 months after quitting. Don't be discouraged if you start smoking again. Remember, most people try several times before they finally quit. Here are some difficult situations to watch for:

• Alcohol. Avoid drinking alcohol. Drinking lowers your chances of success.
• Other smokers. Being around smoking can make you want to smoke.
• Weight gain. Many smokers will gain weight when they quit, usually less than 10 pounds. Eat a healthy diet and stay active. Don't let weight gain distract you from your main goal -- quitting smoking. Some quit-smoking medications may help delay weight gain.
• Bad mood or depression. There are a lot of ways to improve your mood other than smoking.

If you are having problems with any of these situations, talk to your doctor or other health care provider.

Adapted from You Can Quit Smoking (revised 2000)
Consumer Guide
U.S. Public Health Service
June 2000

Reviewed by athealth on February 4, 2014.

Many older people worry about becoming more forgetful. They think forgetfulness is the first sign of Alzheimer's disease. In the past, memory loss and confusion were considered a normal part of aging. However, scientists now know that most people remain both alert and able as they age, although it may take them longer to remember things.A lot of people experience memory lapses. Some memory problems are serious, and others are not. People who have serious changes in their memory, personality, and behavior may suffer from a form of brain disease called dementia. Dementia seriously affects a person's ability to carry out daily activities. Alzheimer's disease is one of many types of dementia.

The term dementia describes a group of symptoms that are caused by changes in brain function. Dementia symptoms may include asking the same questions repeatedly; becoming lost in familiar places; being unable to follow directions; getting disoriented about time, people, and places; and neglecting personal safety, hygiene, and nutrition. People with dementia lose their abilities at different rates.

Dementia is caused by many conditions. Some conditions that cause dementia can be reversed, and others cannot. Further, many different medical conditions may cause symptoms that seem like Alzheimer's disease, but are not. Some of these medical conditions may be treatable. Reversible conditions can be caused by a high fever, dehydration, vitamin deficiency and poor nutrition, bad reactions to medicines, problems with the thyroid gland, or a minor head injury. Medical conditions like these can be serious and should be treated by a doctor as soon as possible.

Sometimes older people have emotional problems that can be mistaken for dementia. Feeling sad, lonely, worried, or bored may be more common for older people facing retirement or coping with the death of a spouse, relative, or friend. Adapting to these changes leaves some people feeling confused or forgetful. Emotional problems can be eased by supportive friends and family, or by professional help from a doctor or counselor.

The two most common forms of dementia in older people are Alzheimer's disease and multi-infarct dementia (sometimes called vascular dementia). These types of dementia are irreversible, which means they cannot be cured. In Alzheimer's disease, nerve cell changes in certain parts of the brain result in the death of a large number of cells. Symptoms of Alzheimer's disease begin slowly and become steadily worse. As the disease progresses, symptoms range from mild forgetfulness to serious impairments in thinking, judgment, and the ability to perform daily activities. Eventually, patients may need total care.

In multi-infarct dementia, a series of small strokes or changes in the brain's blood supply may result in the death of brain tissue. The location in the brain where the small strokes occur determines the seriousness of the problem and the symptoms that arise. Symptoms that begin suddenly may be a sign of this kind of dementia. People with multi-infarct dementia are likely to show signs of improvement or remain stable for long periods of time, then quickly develop new symptoms if more strokes occur. In many people with multi-infarct dementia, high blood pressure is to blame. One of the most important reasons for controlling high blood pressure is to prevent strokes.

Diagnosis

People who are worried about memory problems should see their doctor. If the doctor believes that the problem is serious, then a thorough physical, neurological, and psychiatric evaluation may be recommended. A complete medical examination for memory loss may include gathering information about the person's medical history, including use of prescription and over-the-counter medicines, diet, past medical problems, and general health. Because a correct diagnosis depends on recalling these details accurately, the doctor also may ask a family member for information about the person.

Tests of blood and urine may be done to help the doctor find any problems. There are also tests of mental abilities (tests of memory, problem solving, counting, and language). A brain CT scan may assist the doctor in ruling out a curable disorder. A scan also may show signs of normal age-related changes in the brain. It may be necessary to have another scan at a later date to see if there have been further changes in the brain.

Alzheimer's disease and multi-infarct dementia can exist together, making it hard for the doctor to diagnose either one specifically. Scientists once thought that multi-infarct dementia and other types of vascular dementia caused most cases of irreversible mental impairment. They now believe that most older people with irreversible dementia have Alzheimer's disease.

Treatment

Even if the doctor diagnoses an irreversible form of dementia, much still can be done to treat the patient and help the family cope. A person with dementia should be under a doctor's care, and may see a neurologist, psychiatrist, family doctor, internist, or geriatrician. The doctor can treat the patient's physical and behavioral problems and answer the many questions that the person or family may have.

For some people in the early and middle stages of Alzheimer's disease, the drugs tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) are prescribed to possibly delay the worsening of some of the disease's symptoms. Doctors believe it is very important for people with multi-infarct dementia to try to prevent further strokes by controlling high blood pressure, monitoring and treating high blood cholesterol and diabetes, and not smoking.

Many people with dementia need no medication for behavioral problems. But for some people, doctors may prescribe medications to reduce agitation, anxiety, depression, or sleeping problems. These troublesome behaviors are common in people with dementia. Careful use of doctor-prescribed drugs may make some people with dementia more comfortable and make caring for them easier.

A healthy diet is important. Although no special diets or nutritional supplements have been found to prevent or reverse Alzheimer's disease or multi-infarct dementia, a balanced diet helps maintain overall good health. In cases of multi-infarct dementia, improving the diet may play a role in preventing more strokes.

Family members and friends can assist people with dementia in continuing their daily routines, physical activities, and social contacts. People with dementia should be kept up-to-date about the details of their lives, such as the time of day, where they live, and what is happening at home or in the world. Memory aids may help in the day-to-day living of patients in the earlier stages of dementia. Some families find that a big calendar, a list of daily plans, notes about simple safety measures, and written directions describing how to use common household items are very useful aids.

Advice for Today

Scientists are working to develop new drugs that someday may slow, reverse, or prevent the damage caused by Alzheimer's disease and multi-infarct dementia. In the meantime, people who have no dementia symptoms can try to keep their memory sharp.

Some suggestions include developing interests or hobbies and staying involved in activities that stimulate both the mind and body. Giving careful attention to physical fitness and exercise also may go a long way toward keeping a healthy state of mind. Limiting the use of alcoholic beverages is important, because heavy drinking over time can cause permanent brain damage.

Many people find it useful to plan tasks; make "things-to-do" lists; and use notes, calendars, and other memory aids. They also may remember things better by mentally connecting them to other meaningful things, such as a familiar name, song, or lines from a poem.

Stress, anxiety, or depression can make a person more forgetful. Forgetfulness caused by these emotions usually is temporary and goes away when the feelings fade. However, if these feelings last for a long period of time, getting help from a professional is important. Treatment may include counseling or medication, or a combination of both.

Some physical and mental changes occur with age in healthy people. However, much pain and suffering can be avoided if older people, their families, and their doctors recognize dementia as a disease, not part of normal aging.

Resources

The Alzheimer's Association is a nonprofit organization offering information and support services to people with Alzheimer?s disease and their families. For more information, contact:

Alzheimer?s Association
919 Michigan Avenue, Suite 1100
Chicago, IL 60611-1676
1-800-272-3900
e-mail: [email protected]
Internet: www.alz.org
The Alzheimer's Disease Education and Referral (ADEAR) Center is a service of the National Institute on Aging, part of the Federal Government?s National Institutes of Health. The Center provides information to health professionals, Alzheimer?s disease patients and their families, and the public.

ADEAR Center
PO Box 8250
Silver Spring, MD 20907-8250
1-800-438-4380
e-mail: [email protected]
Internet: www.alzheimers.org
Families often need information about community resources, such as home care, adult day care, respite programs, and nursing homes. This information usually is available from State and Area Agencies on Aging. For help in finding the appropriate agency in your area, call the Eldercare Locator, toll-free at 1-800-677-1116 or visit www.eldercare.gov.

National Institute on Aging
2002

Reviewed by athealth on February 4, 2014.