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The Nature of Resilience

Some longitudinal studies, several of which follow individuals over the course of a lifespan, have consistently documented that between half and two-thirds of children growing up in families with mentally ill, alcoholic, abusive, or criminally involved parents or in poverty-stricken or war-torn communities do overcome the odds and turn a life trajectory of risk into one that manifests "resilience," the term used to describe a set of qualities that foster a process of successful adaptation and transformation despite risk and adversity. Resilience research validates prior research and theory in human development that has clearly established the biological imperative for growth and development that exists in the human organism and that unfolds naturally in the presence of certain environmental characteristics. We are all born with an innate capacity for resilience, by which we are able to develop social competence, problem-solving skills, a critical consciousness, autonomy, and a sense of purpose.

Social competence includes qualities such as responsiveness, especially the ability to elicit positive responses from others; flexibility, including the ability to move between different cultures; empathy; communication skills; and a sense of humor. Problem-solving skills encompass the ability to plan; to be resourceful in seeking help from others; and to think critically, creatively, and reflectively. In the development of a critical consciousness, a reflective awareness of the structures of oppression (be it from an alcoholic parent, an insensitive school, or a racist society) and creating strategies for overcoming them has been key.

Autonomy is having a sense of one's own identity and an ability to act independently and to exert some control over one's environment, including a sense of task mastery, internal locus of control, and self-efficacy. The development of resistance (refusing to accept negative messages about oneself) and of detachment (distancing oneself from dysfunction) serves as a powerful protector of autonomy. Lastly, resilience is manifested in having a sense of purpose and a belief in a bright future, including goal direction, educational aspirations, achievement motivation, persistence, hopefulness, optimism, and spiritual connectedness.

From this research on resilience, from the literature on school effectiveness (Comer, 1984; Edmonds, 1986; Rutter et al., 1979), and from a rich body of ethnographic studies in which we hear the voices of youth, families, and teachers explaining their successes and failures (Heath & McLaughlin, 1993; Weis Fine, 1993), a clear picture emerges of those characteristics of the family, school, and community environments that may alter or even reverse expected negative outcomes and enable individuals to circumvent life stressors and manifest resilience despite risk. These "protective factors" or "protective processes" can be grouped into three major categories: caring and supportive relationships, positive and high expectations, and opportunities for meaningful participation.

Caring Relationships

School can be tough on children with ADHD or learning disabilities. These children may not be able to complete their homework on time. They may struggle to establish friendships with peers, and they may suffer from low self-esteem.

The presence of at least one caring person--someone who conveys an attitude of compassion, who understands that no matter how awful a child's behavior, the child is doing the best he or she can given his or her experience--provides support for healthy development and learning. Werner and Smith's (1989) study, covering more than 40 years, found that, among the most frequently encountered positive role models in the lives of resilient children, outside of the family circle, was a favorite teacher who was not just an instructor for academic skills for the youngsters but also a confidant and positive model for personal identification. Furthermore, as the research of Noddings (1988) has articulated, a caring relationship with a teacher gives youth the motivation for wanting to succeed: "At a time when the traditional structures of caring have deteriorated, schools must become places where teachers and students live together, talk with each other, take delight in each other's company....It is obvious that children will work harder and do things...for people they love and trust." Even beyond the teacher-student relationship, creating a schoolwide ethos of caring creates the opportunities for caring student-to-student, teacher-to-teacher, and teacher-to-parent relationships. An ethic of caring is obviously not a "program" or "strategy" per se, but rather a way of being in the world, a way of relating to youth, their families, and each other that conveys compassion, understanding, respect, and interest. It is also the wellspring from which flow the two other protective factors.

High Expectations

Research has indicated that schools that establish high expectations for all youth--and give them the support necessary to achieve them--have high rates of academic success. They also have lower rates of problem behaviors such as dropping out, drug abuse, teen pregnancy, and delinquency than other schools (Rutter et al., 1979). The conveying of positive and high expectations in a classroom and school occurs at several levels. The most obvious and powerful is at the relationship level in which the teacher and other school staff communicate the message that the student has everything he or she needs to be successful. As Tracy Kidder (1990) writes, "For children who are used to thinking of themselves as stupid or not worth talking to...a good teacher can provide an astonishing revelation. A good teacher can give a child at least a chance to feel, She thinks I'm worth something; maybe I am'." Through relationships that convey high expectations, students learn to believe in themselves and in their futures, developing the critical resilience traits of self-esteem, self-efficacy, autonomy, and optimism.

Schools also communicate expectations in the way they are structured and organized. The curriculum that supports resilience respects the way humans learn. Such a curriculum is thematic, experiential, challenging, comprehensive, and inclusive of multiple perspectives--especially those of silenced groups. Instruction that supports resilience focuses on a broad range of learning styles; builds from perceptions of student strengths, interests, and experience; and is participatory and facilitative, creating ongoing opportunities for self-reflection, critical inquiry, problem solving, and dialogue. Grouping practices that support resilience promote heterogeneity and inclusion, cooperation, shared responsibility, and a sense of belonging. And, lastly, evaluation that supports resilience focuses on multiple intelligences, utilizes authentic assessments, and fosters self-reflection.

Opportunities for Participation

Providing youth with opportunities for meaningful involvement and responsibility within the school is a natural outcome in schools that have high expectations. Participation, like caring and respect, is a fundamental human need. Several educational reformers believe that when schools ignore these basic needs of both students and teachers, schools become alienating places (Sarason, 1990). On the other hand, certain practices provide youth with opportunities to give their gifts back to the school community and do indeed foster all the traits of resilience. These practices include asking questions that encourage critical thinking and dialogue (especially around current social issues), making learning more hands-on, involving students in curriculum planning, using participatory evaluation strategies, letting students create the governing rules of the classroom, and employing cooperative approaches (such as cooperative learning, peer helping, cross-age mentoring, and community service).

Conclusion

Along with other educational research, research on resilience gives educators a blueprint for creating schools where all students can thrive socially and academically. Research suggests that when schools are places where the basic human needs for support, respect, and belonging are met, motivation for learning is fostered. Reciprocal caring, respectful, and participatory relationships are the critical determining factors in whether a student learns; whether parents become and stay involved in the school; whether a program or strategy is effective; whether an educational change is sustained; and, ultimately, whether a youth feels he or she has a place in this society. When a school redefines its culture by building a vision and commitment on the part of the whole school community that is based on these three critical factors of resilience, it has the power to serve as a "protective shield" for all students and a beacon of light for youth from troubled homes and impoverished communities.

For More Information

1. Benard, B. (1991). Fostering Resiliency in Kids: Protective Factors in the Family, School, and Community. San Francisco: Far West Laboratory for Educational Research and Development. ED 335 781.
2. Comer, J. (1984). Home-School Relationships as They Affect the Academic Success of Children. Education and Urban Society 16: 323-337.
3. Edmonds, R. (1986). Characteristics of Effective Schools. In U. Neisser, Ed., The School Achievement of Minority Children: New Perspectives (pp. 93-104). Hillsdale, NJ: Lawrence Erlbaum. ED 269 500.
4. Garmezy, N. (1991). Resiliency and Vulnerability to Adverse Developmental Outcomes Associated with Poverty. American Behavioral Scientist 34: 416-430. EJ 430 590.
5. Heath, S.B., and M.W. McLaughlin, Eds. (1993). Identity and Innter-City Youth: Beyond Ethnicity and Gender. New York: Teachers College Press. ED 360 415.
6. Kidder, T. (1990). AMONG SCHOOL CHILDREN. New York: Avon. Noddings, N. (1988). Schools Face Crisis in Caring. Education Week, December 7.
7. Rutter, M., B. Maughan, P. Mortimore, J. Ouston, and A. Smith. (1979). Fifteen Thousand Hours. Cambridge, MA: Harvard University Press.
8. Sarason, S. (1990). The Predictable Failure of Educational Reform. San Francisco: Jossey-Bass. ED 354 587.
9. Weis, L., and M. Fine, Eds. (1993). Beyond Silenced Voices: Class, Race, and Gender in United States Schools. New York: State University of New York Press. ED 361 416.
10. Werner, E., and R. Smith. (1989). Vulnerable But Invincible: A Longitudinal Study of Resilient Children and Youth. New York: Adams, Bannister, and Cox.
11. Werner, E., and R. Smith. (1992). Overcoming the Odds: High-Risk Children from Birth to Adulthood. New York: Cornell University Press, 1992. ED 344 979.

ERIC Clearinghouse on Elementary and Early Childhood Education
Author: Bonnie Benard, MSW
August 1995

Reviewed by athealth on February 4, 2014.

by Emily Sue Harvey

Four Ways to Stay in Tune

1. Fill Your Place. My father’s sudden, accidental death drove this home to me. My biological mother died when I was ten. My wonderful stepmother, my other “Mom,” was my surrogate parent from the tender age of eleven.

Years later, when Dad died, the earth was yanked from beneath me. I wasn’t certain, in those hours, who I was exactly, with 2 full siblings and three half-siblings. Oh, we’d never even used the ‘half’ term. We’re extremely close.

But was Dad, father to us all, after all, the glue? In my initial shocked state, the family unit felt shattered. But hours later, when I entered Mom’s house (not Dad’s anymore) I heard her call, “Susie,” her voice soothing as she sailed like a porpoise and gathered me into her arms. “I’m sorry about Daddy. He’s with your Mama now,” she whispered, tears in her eyes. I was aghast at her selflessness in that moment.

And my place in the family galvanized. I’ve seen family members vacate that space because some sibling, parent, or relative offended them. They were willing to abdicate their rightful position in the orchestra, creating dissonance and frailty of tone. The perception is yours. And only you can take your place. The orchestra is not quite right, a bit hollow, without you there playing your notes.

2. Play the Right Notes. We all hit sour notes in our families. All of us miss opportunities to keep the family harmony solid. One way to do that is to simply ‘be there’ for each other. I’ll never forget failing in that role. While in my teens, with a new boyfriend, my little sister asked me to please ask Lee, my beau, go get some toothache drops. His was the only car available at the moment. Her tooth hurt. Living in a rural area with no corner seven-eleven or pharmacy, I dropped the ball, not willing to ask Lee to aid in the problem.

Looking back, I see that he would have gladly done so but at that time my insecurity prevailed. Later in the evening, an aunt came by, saw Patsy’s problem and immediately drove to a neighbor’s, borrowed the merciful pain reliever and administered first aid to my relieved sister. For years, I carried guilt. I’ve since tried to remedy that lapse. But it was a hard lesson learned about just being there.

3. Re-Tune. Forgive the out-of-tune times. Patsy, my above-mentioned sister, married a Baptist minister. Years after my unconscionable lapse of mercy, she invited me to a “special service” at their little country church. Turned out the service was to honor those SPECIAL ONES in folks’ lives. Patsy stood and began speaking. “I want to honor my sister, Susie, today. She’s always been there for me. Always.” She went on extolling virtues I was supposed to possess. Each word made me feel more despicable, like slithering through the floor cracks. Smiling, she presented me with the certificate bearing my name. Later, after service, I apologized again for that long ago night when she had a toothache. She looked puzzled. “I don’t remember,” she said, shrugging. “But I’ll forgive you anyway. I only remember what a great sister you were, always validating and nurturing me.” She didn’t remember. I was forgiven. Wow. I felt renewed inside and out. It was re-tuning time!

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4. It’s Not All About Me. Family is the ultimate, universal orchestra. Family is teamwork at its quintessential best. One reason it’s so effective is that it’s propelled by love. So why do families erupt into chaotic dissonance? It usually starts with a “what about me?” attitude.

Granted, we’re more relaxed with family, more prone to just let ‘er rip with the let’s play fair, now! And that’s okay. We do, to a great degree, police each other within the family unit, do a regular power check and balance. It’s when one or more members refuse to let go of the’ what about me?’… long enough to do family/team negotiation.

The scratchy dissonance grows in direct proportion to the self-absorption, the my way or the highway mentality. My mother’s recent death required our six siblings to perform like the Boston Pops Orchestra regarding the proceedings of the probate, will, organization of estate sale, the actual estate sale, and distribution of the estate.

Two sisters were more able to do the organizing. One, because of health problems, was not able to assist. Two brothers helped with the heavy lifting during organization and estate sale. One brother lived too far away to participate. And guess what? It was okay that four did most of the work. Unconditional love and teamwork made the entire process sound like the Hundred and One Strings Orchestra playing Debussy’s Claire De Lune!

So, tune up your love and take your place in the family band. Make music to the renewal of mind, spirit, and body!

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About the Author

Emily Sue Harvey writes to make a difference. Her upbeat stories have appeared in dozens of anthologies including Chicken Soup for the Soul, Chocolate for Women, From Eulogy to Joy, A Father’s Embrace, True Story, Compassionate Friends Magazine, and Woman’s World. Emily Sue served as president of Southeastern Writers Association in 2008-2009. Peter Miller’s NY Literary and Film Agency represent Emily Sue. Her first novel, Song of Renewal, published by Story Plant, will be released in the spring of 2009. For more information visit www.renewalstories.com. Used with permission.

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Page last modified or reviewed by AH on December 9, 2010

What is genital herpes?

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2).

How common is genital herpes?

Genital herpes infection is common in the United States. Nationwide, 16.2%, or about one out of six, people aged 14 to 49 years have genital HSV-2 infection. Over the past decade, the percentage of persons with genital herpes infection in the United States has remained stable.

Transmission from an infected male to his female partner is more likely than from an infected female to her male partner. Because of this, genital HSV-2 infection is more common in women (approximately one out of five women aged 14 to 49 years) than in men (about one out of nine men aged 14 to 49 years).

How do people get genital herpes?

People get herpes by having sex with someone who has the disease. "Having sex" means anal, vaginal, or oral sex. HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause. The viruses can also be released from skin that does not appear to have a sore. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected.

HSV-1 can cause sores in the genital area and infections of the mouth and lips, so-called "fever blisters." HSV-1 infection of the genitals is caused by mouth to genital or genital to genital contact with a person who has HSV-1 infection.

What are the signs and symptoms of genital herpes?

Most individuals infected with HSV-1 or HSV-2 experience either no symptoms or have very mild symptoms that go unnoticed or are mistaken for another skin condition. Because of this, most people infected with HSV-2 are not aware of their infection. When symptoms do occur, they typically appear as one or more blisters on or around the genitals, rectum or mouth. The blisters break and leave painful sores that may take two to four weeks to heal. Experiencing these symptoms is sometimes referred to as having an "outbreak." The first time someone has an outbreak they may also experience flu-like symptoms such as fever, body aches and swollen glands.

Repeat outbreaks of genital herpes are common, in particular during the first year of infection. Symptoms of repeat outbreaks are typically shorter in duration and less severe than the first outbreak of genital herpes. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years. What are the complications of genital herpes?

Genital herpes can cause painful genital sores in many adults and can be severe in people with suppressed immune systems. If a person with genital herpes touches their sores or the fluids from the sores, they may transfer herpes to another part of the body. This is particularly problematic if it is a sensitive location such as the eyes. This can be avoided by not touching the sores or fluids. If they are touched, immediate and thorough hand-washing make the transfer less likely.

Some people who contract genital herpes have concerns about how it will impact their overall health, sex life, and relationships. It is best to talk to a health care provider about those concerns, but it also is important to recognize that while herpes is not curable, it is a manageable condition. Since a genital herpes diagnosis may affect perceptions about existing or future sexual relationships, it is important to understand how to talk to sexual partners about STDs.

There are also potential complications for a pregnant woman and her unborn child.

What is the link between genital herpes and HIV?

Genital herpes can cause sores or breaks in the skin or mucous membranes (lining of the mouth, vagina, and rectum). The genital sores caused by herpes can bleed easily. When the sores come into contact with the mouth, vagina, or rectum during sex, they increase the risk of HIV transmission if either partner is HIV-infected.

How does genital herpes affect a pregnant woman and her baby?

It is crucial that pregnant women infected with HSV-1 or HSV-2 go to prenatal care visits and tell their doctor if they have ever experienced any symptoms of, been exposed to, or been diagnosed with genital herpes. Sometimes genital herpes infection can lead to miscarriage or premature birth. Herpes infection can be passed from mother to child resulting in a potentially fatal infection (neonatal herpes). It is important that women avoid contracting herpes during pregnancy.

A woman with genital herpes may be offered antiviral medication from 36 weeks gestation through delivery to reduce the risk of an outbreak. At the time of delivery a woman with genital herpes should undergo careful examination. If herpes symptoms are present at delivery, a cesarean delivery (also called a 'C-section') is usually performed.

How is genital herpes diagnosed? 

Health care providers can diagnose genital herpes by visual inspection if the outbreak is typical. Providers can also take a sample from the sore(s) and test it. Sometimes, HSV infections can be diagnosed between outbreaks with a blood test. A person should discuss such testing options with their health care provider.

Is there a cure or treatment for herpes?

There is no treatment that can cure herpes. Antiviral medications can, however, prevent or shorten outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy (i.e., daily use of antiviral medication) for herpes can reduce the likelihood of transmission to partners.

How can herpes be prevented? 

Correct and consistent use of latex condoms can reduce the risk of genital herpes, because herpes symptoms can occur in both male and female genital areas that are covered or protected by a latex condom. However, outbreaks can occur in areas that are not covered by a condom.

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Persons with herpes should abstain from sexual activity with partners when sores or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms, he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected and they should use condoms to reduce the risk. Sex partners can seek testing to determine if they are infected with HSV.

Source: Centers for Disease Control and Prevention
Page last updated by CDC: September 19, 2012

Reviewed by athealth on February 8, 2014.

Attention Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder of childhood, and is marked by a constellation of symptoms including immature levels of impulsivity, inattention, and hyperactivity (American Psychiatric Association, 1994). The National Institutes of Health declared ADHD a "severe public health problem" in its consensus conference on ADHD in 1998. In the ongoing dialogue about ADHD in gifted children, three questions often arise. Are gifted children over-diagnosed with the disorder? In what ways are gifted ADHD children different from gifted children without the disorder and from other ADHD children? Does the emerging research suggest any differences in intervention or support?

There are three subtypes of ADHD: predominantly inattentive type, predominantly hyperactive/impulsive type, and combined type. The combined type is most common and best researched. The DSM-IV states that to meet criteria for a diagnosis of Combined Type ADHD, a child must meet at least six of the nine criteria from both lists and exhibit significant impairment in functioning. Symptoms must occur in more than one setting, have been present for at least six months, and have been present before the age of seven. It is important to note that a child who meets the criteria but doesn't exhibit significant impairment is not diagnosed with the disorder. The subjective determination of what constitutes significant impairment is one of several factors that contribute to the controversy regarding diagnosis and treatment, especially in gifted children.

Differences in Gifted Children and Non-Gifted Children with ADHD

Initial findings suggest two points for consideration (Kalbfleisch, 2000; Kaufmann, Kalbfleisch, & Castellanos, 2000; Moon, 2001; Moon, Zentall, Grskovic, Hall, & Stormant, 2001; Zentall, Moon, Hall, & Grskovic, 2001). First, Kaufman and her colleagues' (2000) work indicates that identified gifted ADHD children are more impaired than other ADHD children, suggesting the possibility that we are missing gifted children with milder forms of ADHD. Second, high ability can mask ADHD, and attention deficits and impulsivity tend to depress the test scores as well as the high academic performance that many schools rely on to identify giftedness. Also, teachers may tend to focus on the disruptive behaviors of gifted ADHD students and fail to see indicators of high ability.

These delays are of concern because early provision of appropriate services is important for academic and social success. Gifted children whose attention deficits are identified later may be at risk for developing learned helplessness and chronic underachievement (Moon, 2001). ADHD children whose giftedness goes unrecognized do not receive appropriate educational services. It is recommended that children who fail to meet test score criteria for giftedness and are later diagnosed with ADHD be retested for the gifted program (Baum, Olenchak, & Owen, 1998; Moon, 2002).

As a group, ADHD children tend to lag two to three years behind their age peers in social and emotional maturity (Barkley, 1998). Gifted ADHD children are no exception (Kaufmann & Castellanos, 2000; Moon, 2001; Zentall, Moon, Hall, & Grskovic, 2001). This finding has important implications for educational placement. As a group, gifted children without ADHD tend to be more similar in their cognitive, social, and emotional development to children two to four years older than children their own age (Neihart, Reis, Robinson, & Moon, 2002). When placed with other high ability children without the disorder, ADHD children may find the advanced maturity of their classmates a challenge they are ill prepared for. Also, gifted children without the disorder may have little patience for the social and emotional immaturity of the gifted ADHD student in their midst. This is not to say that gifted ADHD students should not be placed with other gifted students. The research is clear that lack of intellectual challenge and little access to others with similar interests, ability, and drive are often risk factors for gifted children (Neihart, Reis, Robinson, & Moon, 2002), contributing to social or emotional problems.

Assessing ADHD in Gifted Children

It is difficult to differentiate true attention deficits from the range of temperament and behavior common to gifted children. There is concern in the literature that clinicians err on the side of pathologizing normal gifted behavior (Baum, Olenchak, & Owen, 1998; Baum, Owen & Dixon, 1991; Cramond, 1995; Leroux & Levitt-Perlman, 2000; Webb, 2001). Common characteristics of gifted children can be misconstrued as indicators of pathology when the observer is unfamiliar with the differences in the development of gifted children. This difficulty can be exacerbated when the gifted child in question spends considerable time in a classroom where appropriate educational services are not provided. The intensity, drive, perfectionism, curiosity, and impatience commonly seen in gifted children may, in some instances, be mistaken for indicators of ADHD (Baum, Olenchak, & Owen, 1998; Webb, 2001). The creatively gifted child may appear to be oppositional, hyperactive, and argumentative (Cramond, 1995). Gifted children with some kinds of undiagnosed learning disabilities will be very disorganized, messy, and have difficult social relations (Baum & Owen, & Dixon, 1991; Olenchak & Reis, 2002).

Ideally, a diagnosis of ADHD in gifted children should be made by a multidisciplinary team that includes at least one clinician trained in differentiating childhood psychopathologies and one professional who understands the normal range of developmental characteristics of gifted children. Since as many as two thirds of children with ADHD have coexisting conditions such as learning disabilities or depression, assessment must include an evaluation for these disorders as well (American Academy of Pediatrics, 2000). School personnel rarely have the training needed to differentially diagnose ADHD, and few clinicians are aware of the unique developmental characteristics of gifted children. Accurate assessment must be a team effort.

One of the reasons parents may be hesitant to comply with treatment recommendations for their children is because they aren't convinced their child has the disorder. Parents want a thorough evaluation, and parents of gifted children want assurance that their child's giftedness has been taken into consideration when evaluations are conducted. When parents see that their child has been properly evaluated, they may be more willing to participate in a treatment plan.

What is Appropriate Intervention and Support?

The available research suggests that we should not assume that all interventions recommended for ADHD children are appropriate for gifted children who have the disorder. Early findings suggest that there may be some differences in the way we intervene with gifted ADHD children. Treatment matching is crucial. Effective interventions are always those that are tailored to the unique strengths and needs of the individual. There is wide agreement in the literature on gifted children with learning problems that as a general strategy, intervention should focus on developing the talent while attending to the disability. Keeping the focus on talent development, rather than on remediation of deficits, appears to yield more positive outcomes and to minimize problems of social and emotional adjustment (Baum, Owen & Dixon, 1991; Olenchak, 1994; Olenchak & Reis, 2002; Reis, McGuire, & Neu, 2000).

In addition, there is limited evidence that some of the commonly recommended interventions for ADHD children may make problems worse for ADHD children who are also gifted (Moon, 2002). For instance, since gifted children tend to prefer complexity, shortening work time and simplifying tasks may increase frustration for some gifted ADHD students who would handle better more difficult and intriguing tasks. Similarly, decreasing stimulation may be counterproductive with some gifted ADHD children who, as a group, tend to be intense and work better with a high level of stimulation.

Conclusion

There has been some concern that problems with inattention or hyperactivity that are better attributed to a mismatch with the curriculum (Baum, Olenchak, & Owen, 1998; Webb, 2001) or to characteristics of high creative ability (Cramond, 1995) are wrongly attributed to ADHD. Although there are good reasons to believe that misidentifications occur, there are yet no hard data on the frequency with which gifted children are over- (or under-) diagnosed or over- (or under-) medicated. Until systematic studies are conducted, we should be cautious about rejecting ADHD diagnosis in gifted children out of hand because there are serious, long-term negative consequences for undertreating the disorder (Barkley, 1998). The available research on ADHD children indicates that nationally, there is a good deal of undertreatment as well as some overtreatment of ADHD children.

It is a challenge to arrange a good fit in school for gifted ADHD children. They must have an appropriate level of intellectual challenge with supports and interventions to address their social and emotional immaturity. Placement in the gifted program may or may not be appropriate, depending on the nature of the program, the social milieu of the gifted classroom, and the coping ability of the child, but a coherent plan for addressing the student's intellectual, social, and behavioral needs is nevertheless imperative.

References

1. American Academy of Pediatrics (2000). Clinical practice guidelines: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105:1158-1170.
2. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: Author.
3. Barkley, R.A. (1998). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York, NY: Guilford Press.
4. Baum, S.M., Olenchak, F.R., & Owen, S.V. (1998). Gifted students with attention deficits: Fact and/or fiction? Or, can we see the forest for the trees? Gifted Child Quarterly, 42, 96-104.
5. Baum, S, Owen, S.V., & Dixon, J. (1991). To be gifted and learning disabled: From definition to practical intervention strategies. Mansfield Center, CT: Creative Learning Press.
6. Kalbfleisch, M.L. (2000). Electroencephalographic differences between males with and without ADHD with average and high aptitude during task transitions. Unpublished doctoral dissertation, University of Virginia, Charlottesville.
7. Kaufmann, F.A., & Castellanos, F.X. (2000). Attention-deficit/hyperactivity disorder in gifted students. In K.A. Heller, F.J. Monks, R.J. Sternberg, & R.F. Subotnik (Eds.), International handbook of giftedness and talent. (2nd ed., pp. 621-632). Amsterdam: Elsevier.
8. Kaufmann, F., Kalbfleisch, M. L., & Castellanos, F. X. (2000). Attention deficit disorders and gifted students: What do we really know? Storrs, CT: National Research Center on the Gifted and Talented, University of Connecticut.
9. Leroux, J.A., & Levitt-Perlman, M. (2000). The gifted child with attention deficit disorder: An identification and intervention challenge. Roeper Review, 22, 171-176.
10. Moon, S.M., Zentall, S.S., Grskovic, J.A., Hall, A. & Stormont, M. (2001). Emotional, social, and family characteristics of boys with AD/HD and giftedness: A comparative case study. Journal for the Education of the Gifted, 24, 207-247.
11. Moon, S. (2002). Gifted children with attention deficit/hyperactivity disorder. In M. Neihart, S. Reis, N. Robinson, S. Moon (Eds.). The social and emotional development of gifted children: What do we know? (pp. 193-204). Waco, TX: Prufrock Press.
12. National Institutes of Health (1998). Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) consensus statement. Washington, DC: Author.
13. Neihart, M., Reis, S., Robinson, N., & Moon, S. (Eds.) (2002). The social and emotional development of gifted children: What do we know? Waco, TX: Prufrock Press.
14. Olenchak, R., & Reis, S. (2002). Gifted children with learning disabilities. In M. Neihart, S. Reis, N. Robinson, & S. Moon (Eds.), The social and emotional development of gifted children: What do we know? (pp. 177-192). Waco, TX: Prufrock Press.
15. Olenchak, F.R. (1994). Talent development: Accommodating the social and emotional needs of secondary gifted/learning-disabled students. Journal of Secondary Gifted Education, 5, 40-52.
16. Reis, S.M., McGuire, J.M. & Neu, T.W. (2000). Compensation strategies used by high-ability students with learning disabilities who succeed in college. Gifted Child Quarterly, 44, 123-134.
17. Webb. J.T. (2001). Mis-diagnosis and dual diagnosis of gifted children: Gifted and LD, ADHD, OCD, oppositional defiant disorder. N. Hafenstein & F. Rainey (Eds.), Perspectives in gifted education: Twice exceptional children (pp. 23-31). Denver: Ricks Center for Gifted Children, University of Denver.
18. Zentall, S.S., Moon, S.M., Hall, A.M., & Grskovic, J.A. (2001). Learning and motivational characteristics of boys with AD/HD and/or giftedness. Exceptional Children, 67, 499-519.

ERIC Clearinghouse on Elementary and Early Childhood Education
Author: Maureen Neihart
October 2003

Reviewed by athealth on February 4, 2014.

Society's attention on aggression in children has focused primarily on boys. Many of us assume boys are more aggressive because their forms of aggression are more visible. We see them hitting or fighting on the playgrounds or in our homes. In fact, much of the research on aggressive children has focused on the more overt, physical types of aggression characteristic of boys.

Researcher Nicki Crick of the University of Minnesota and her colleagues argue that research has overlooked aggressive behavior in girls because the patterns of aggression in girls are different than in boys. Most definitions of aggression include behaviors that are intended to hurt or harm others. Nicki Crick and her colleague Jennifer Grotpeter elaborate on that definition by adding that aggression also includes behaviors that best thwart or damage goals that are valued by their respective gender peer groups. (Crick & Grotpeter, 1995, p. 710). Boys generally harm others with physical or verbal aggression because this behavior is consistent with the physical dominance peer group goals of boys. Girls, on the other hand, are more apt to focus their aggression on relational issues with their peers. This behavior is consistent with the social peer group and intimacy goals of girls. This kind of aggression, which Crick and her colleagues call relational aggression, is more characteristic of girls, though not exclusive to girls, and is done with the intention of damaging another child's friendship or feelings of inclusion within a social group (Crick & Grotpeter, 1995, p. 711).

Girls' relational aggression includes a range of behaviors such as excluding another child from a play group as a form of retaliation, intentionally withdrawing friendship as a way of hurting or controlling a child, and spreading rumors about a child to persuade peers to reject her (Crick & Grotpeter, 1995, p. 711). Patterns of relational aggression are seen in girls as young as 3 to 5 years of age (Crick, Casas, & Mosher, 1997, p. 585) and appear to be relatively stable over time (Crick, 1996, p. 2326).

Should parents be concerned about girls who engage in this kind of aggression? Does this kind of behavior cause any real harm? The answer to both questions is yes. Relationally aggressive girls have more social and emotional problems and experience more loneliness, depression, negative self-perceptions, and peer rejection than others. Those who are victims of relationally aggressive behaviors also experience adjustment problems and report more depression, anxiety, and emotional distress than their non-targeted peers (Crick, Casas, & Mosher, 1997, p. 579).

Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. The are more likely than their peers to bully and be bullied.

Problems with peers affect children in multiple ways. Gary Ladd's Pathways Project, a long-term study of children from kindergarten through junior high school, looks at aspects of family and school that affect children's academic success. Ladd found that the kinds of relationships children form with peers once they get into school matter a great deal. When children have difficulty with their peer group at the start of school, they do less well on measures of learning and achievement. Similarly, children who are consistently victimized teased or hit are more likely to develop negative views of school, are more lonely, have more physical complaints, and display higher levels of school avoidance (Patten, 1999).

Children who are rejected by their peers continue to experience problems later in life, such as dropping out of school, juvenile delinquency, and mental health problems (Asher & Williams, 1993). Furthermore, antisocial behavior in girls during their childhood and teen years is found to persist into adulthood with higher rates of criminality, teen pregnancy, and adult depression (Antisocial Behavior in Girls,. 1999, pp. 1, 7).

What, then, should parents do if they observe relationally aggressive behaviors in children? First, parents can recognize that relationally aggressive children are at risk for adjustment difficulties, just as overtly aggressive children are. Second, parents can use opportunities to develop children's social skills. Ladd's Pathways Project found that parents help children develop effective social skills in a number of ways: for example, by inviting friends over and arranging for children to join in group play with other children; by talking to their child about what it means to be a host and how to look out for the other child's needs; and by intervening when problems arise in play groups and talking to their child about fairness, turn taking, sharing, and resolving dilemmas through compromise and discussion. In all these ways, Ladd says, parents are teaching social competence - how to make and maintain a friendship with another child (Patten, 1999).

Research tells us that aggressive behavior during childhood predicts later social adjustment problems (Crick, 1996, p. 2317). While boys and girls may exhibit their aggression and cruelty in different ways, the effects can be equally damaging.

For More Information

1. Asher, Stephen R., & Williams, Gladys A. (1993). Children without friends, part 2: The reasons for peer rejection. In Todd, C. M. (Ed.), Day Care Center Connections, 3(1), 3-5. Urbana-Champaign, IL: University of Illinois Cooperative Extension Service. Available at: http://www.nncc.org/Guidance/dc31_wo.friends2.html [2000, June 1].
2. Clark, Ann-Marie. (1998). Helping young children make friends at school. Parent News [Online], 4(9). Available at: http://npin.org/pnews/1998/pnew998/inte998a.html [2000, June 1].
3. Craig, Wendy. (1997). Queen's study links childhood bullying with sexual harassment and violence in teens [Online]. Greensboro, NC: ERIC Clearinghouse on Counseling and Student Services. Available at: http://www.uncg.edu/edu/ericcass/bullying/DOCS/queens.htm [2000, June 2].
4. DeAngelis, Tori. (1997). Abused children have more conflicts with friends. APA Monitor, [Online], 28(6). Available at: http://www.uncg.edu/edu/ericcass/conflict/docs/friends.htm [2000, June 2].
5. Hartup, Willard W. (1992). Having friends, making friends, and keeping friends: Relationships as educational contexts. ERIC Digest. Champaign, IL. ERIC Clearinghouse on Elementary and Early Childhood Education. (ERIC Document No. ED345854 ). Available at: http://ericeece.org/pubs/digests/1992/hartup92.html [2000, May 14].
6. Mounts, Nina S. (1997). What about girls? Are they really not aggressive? Human Development and Family Life Bulletin [Online], 3(2). Available at: http://www.hec.ohio-state.edu/famlife/bulletin/volume.3/bull26b.htm [2000, May 15].
7. Mounts, Nina S. (1997). Aggression and peer rejected children. Human Development and Family Life Bulletin [Online], 3(2). Available at: http://www.hec.ohio-state.edu/famlife/bulletin/volume.3/bull26f.htm [2000, May 14].
8. Weiler, Jeanne. (1999). Girls and violence. ERIC Digest. New York: ERIC Clearinghouse on Urban Education. (ERIC Document No. ED430069). Available at: http://eric-web.tc.columbia.edu/digests/dig143.html [2000, May 14].
9. Williams, Gladys A., & Asher, Stephen R. (1993). Children without friends, part 3: Learning about a child.s strengths and weaknesses. In Todd, C. M. (Ed.), Day Care Center Connections, 3(2), 3-4. Urbana-Champaign, IL: University of Illinois Cooperative Extension Service. Available at: http://www.nncc.org/Guidance/dc32_wo.friends3.html [2000, June 16].
10. Williams, Gladys A., & Asher, Stephen R. (1993). Children without friends, part 4: Improving social skills. In Todd, C. M. (Ed.), Day Care Center Connections, 3(2), 3-6. Urbana-Champaign, IL: University of Illinois Cooperative Extension Service. Available at: http://www.nncc.org/Guidance/sac32_wo.friends4.html [2000, June 16].

Resources

1. Antisocial behavior in girls persists into adulthood. (1999). Brown University Child and Adolescent Behavior Letter, 15(5), 1, 7.
2. Asher, Steven R., & Williams, Gladys A. (1993). Children without friends, part 1: Their problems. In Todd, C. M. (Ed.), Day Care Center Connections, 2(6), 3-4. Urbana-Champaign, IL: University of Illinois Cooperative Extension Service. http://www.nncc.org/Guidance/dc26_wo.friends1.html [2000, May 14].
3. Crick, Nicki R. (1996). The role of overt aggression, relational aggression, and prosocial behavior in the prediction of children's future social adjustment. Child Development, 67(5), 2317-2327. (ERIC Journal No. EJ539853)
4. Crick, Nicki R.; Casas, Juan F.; & Mosher, M. (1997). Relational and overt aggression in preschool. Developmental Psychology, 33(4), 579-588. (ERIC Journal No. EJ549585)
5. Crick, Nicki R., & Grotpeter, Jennifer K. (1995). Relational aggression, gender, and social-psychological adjustment. Child Development, 66(3), 710-722. (ERIC Journal No. EJ503787)
6. Patten, Peggy. (1999). Pathways Project: An interview with Gary Ladd. Parent News [Online], 5(4). http://npin.org/pnews/1999/pnew799/int799c.html [2000, May 14].

Document Source
Patten, Peggy. (2000). Girls, Aggressive? Parent News [Online], 6(4). Available at: http://npin.org/pnews/2000/pnew700/int700d.html

Reviewed by athealth on February 5, 2014.

by James Lehman, MSW

If you and your spouse take opposing roles in dealing with your kids, you're not alone. Many parents take on the roles of "good cop" and "bad cop" in the family. For instance, Dad is the kid's best buddy, and mom is the nag. Or dad is strict and mom is a sympathizer.

Which "cop" is right? And should you be a cop at all?

I see two problems with the notion of good cop/bad cop parenting. First, is the very idea that somebody has to be a "cop" all the time. Parents don't need to be cops. They simply need to be coaches and teachers for their children.

Second, what's really happening when parents become good cops and bad cops is that the kids have learned to split their parents. The area of the split is where kids go to get out of meeting their responsibilities.

For example, Tommy goes to mom and says, "Dad's making me clean my room before we go to the mall." Or he says to mom, "Why do I have to clean my room? Dad doesn't make me do it." When your child makes complaints like this, both parents have to be supportive of each other. You have to be able to say, "These are the rules Dad and I both have, and you have to do it or you're going to be held responsible for the consequences." Then turn around and walk away. That's it. Give simple statements of support. The more unified you are as parents, the more likely your child is to complete his responsibilities, because he doesn't have another way out. The only way out is to act responsibly and do what's asked of him.

But what if you don't really agree with what Dad is asking Tommy to do? If you have a problem with a rule or limit your spouse sets or a request that's being made of your kid, don't make a face. Don't sigh. And, by all means, don't argue with your spouse about the issue in front of the child...or even indicate that you are going to argue. Just tell your child he has to do what's been asked of him. Then talk with your spouse later, after the kids have gone to bed and out of earshot. This is important, because kids pick up on non-verbal cues from their parents a lot more than you think. If your child sees that you disagree with what's being asked of him, he'll bring up the issue again and again, to split you and your spouse and to avoid meeting the responsibility.

Simple statements of support work when you use them consistently. When Tommy complains that Dad won't let him play Runescape before he does his homework, and you say, "Your father said you can't play Runescape until you do your homework. That's the rule," you can bet Tommy will stop trying to split you and your spouse.

Good Cop/Bad Cop Parenting reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: James Lehman is a behavioral therapist and the creator of The Total Transformation® Program for parents. He has worked with troubled children and teens for three decades. James holds a Masters Degree in Social Work from Boston University.

Reviewed by athealth on February 5, 2014.

Making It Work

Even with all the advantages of an extended family, the course of those relationships doesn't always run smooth. Parents and grandparents are bound to disagree over child-rearing choices. The trick is in knowing how to cool the friction before the fire gets out of hand.

• What most young parents need from their own parents is sympathetic support, not advice and criticism. While it's sometimes painful to watch your children go through the trial-and-error of parenthood, it's part of their learning curve. It's best to let them know you're there for them, that you're willing and eager to listen and that you'd be glad to offer the wisdom of your own experience if and when they want it. A regular "date" with them to let your child unload is a sure way of keeping in touch.
• Occasionally, our children or grandchildren will do something we feel so strongly about, we'll want to intervene right then and there. Resist temptation. It only undermines the parents in front of the children and sets up tensions. The time to talk about the problem is calmly and reasonably and privately. Even if you ultimately disagree, it inspires trust when you accept their parenting decisions. Remind your children of their own childhood crises and how they handled them.
• Grandparents must respect their children as the parents. Grandparents are notorious for overindulging their young charges, and parents often worry that this will undercut their own child-rearing efforts. However, Grandma and Grandpa's treats, no matter how frequent, are just one more sign to children that they are cherished. Grandparents can be tolerant, loving and supportive, without having to discipline and instruct the way parents must. They can afford to see all the good things in a child and ignore the bad. That's a wonderful mirror into which a child can look.
• Children always know that their parents' insistence on proper nutrition and a sensible bedtime is good and loving in the most profound sense. So when it comes to major issues, grandparents should always abide by the limits set by the parents to avoid confusion and bad feeling on all sides.
• One of the great gifts we have is our ability to influence young children. Removed from the power struggles of the immediate family a grandparent isn't likely to meet with as much resistance as a parent would in suggesting a child do some homework or set the table. It is one way grandparents help parents by reinforcing the values that parents want to instill.

T. Berry Brazelton, MD

Let your children know that you made more than your share of mistakes when they were little, and that, just as they do now, you had to learn how to take good care of them. I will never forget the time when my baby daughter Laura was about to swallow something that looked to her like a piece of cherry candy. It wasn't candy. It was a bright-red glue pellet from a craft set. That is how I learned the importance of baby-proofing our home.

• Then my grown-up daughter had the fun of reminding me of those lessons when my own grandchildren were little and she brought them to visit me. She went around my house to be sure I had put all the peanuts and candies up high-and locked away the pills-and put safety plugs on the electrical outlets.
• Where babies are concerned, we can all use good advice. But as a grandparent, I try hard not to give it unless I'm asked. It's much better if I wait until I hear, "Mom, I need advice."
• It may be our privilege as grandparents to indulge and maybe even spoil our grandchildren a bit. For example, I may buy more toys or treats for my grandchildren than I did for my daughters. But you need to be careful, too. A friend of mine, a new grandmother, proudly showed me the toy she bought for her two-year-old grandson. The age label on the toy was for an older child. Like me, she thought she had the smartest grandchild imaginable, and the toy would challenge him. But those age labels on toys are often safety recommendations, not measures of skill or ability. By providing appropriate playthings, you can spoil your grandchildren and keep them safe at the same time.
• We're there with the power of example. Try not to force your beliefs. Rather, in a loving and con-versational way, set a good example. For instance, my grandchildren see me in my job giving back to society. They've got the idea that's a good thing from watching what I do and how much I care about child safety. They've become safety ambassadors, very interested in safety for themselves and for their friends. It's your very presence that affects them. You're a grandparent figure. If you're informal, loving, friendly and casual, and you set a good example, it's the best way to encourage learning, values and connection that go beyond your family to the community and society at large.

Ann Brown

Adapted from: A Grandparents' Guide for Family Nurturing & Safety
U.S. Consumer Product Safety Commission
Authors: T. Berry Brazelton and Ann Brown

Reviewed by athealth on February 5, 2014.

What is a psychodynamic process group and how does it typically work?

A process group typically consists of eight individuals who agree to meet regularly for a specific period of time, depending on the kind of group being hosted. Rules and expectations are agreed upon prior to the beginning of the group, and maybe discussed by members during the group if and when the need arises. A common purpose among those individuals who join a process group is in their wanting to find out more about who they are and, what it is perhaps that they would like to see change with-in their personal lives and in their relationships with others. In essence, a process group is expected to increase emotional awareness and relational understanding between self and others. The work of putting emotional experiences into words can give an individual the cognitive and emotional tools that lend to self-learning, insight and the potential to function with an increased sense of freedom, and with increased sophistication.

The premise of a process group draws from a psychodynamic perspective and is based upon developmental theory. The group is not apt to be influenced to change from 'outside' social pressures and cultural values making it a very specialized and unique psychotherapeutic method of healing. The group as a whole shapes its own unique culture, common values and norms thus, creating a meaningful context upon which it can evolve and grow at its own pace.

The life of a process group from the beginning to the end parallels different developmental stages of growth and maturity. As a group moves forward through its natural stages, the members and the "group-as-a-whole" are assisted with guided feedback and process comments from the leader and or co-leaders. As a result, the group inherently knits together with an abundance of experiences forming and emulating a social microcosm that bears its own unique culture and identity.

A most remarkable and natural phenomenon in the earlier stages of a process group is the way in which individuals, and sub-groups alike repeat the many characteristic ways once developed to survive the stressors and strains in the very first group...the family. Members may remind each other of significant others in their past or present circumstances bringing feelings, thoughts, ideas and fantasies to the fore.

One of the most important keys to a successful process group is when all group members feel sufficiently relaxed and safe to talk as openly as they possibly can about any aspects of the group experience in which they choose to respond. By engaging with one another on different emotional levels, individuals will hopefully gain wider perspectives about the various ways they relate to their inner world and understand how this becomes reflected in their relationships with others.

As awareness increases individuals may begin to recognize newly found aspects of themselves. Individuals and 'the-group-as-a-whole' may actively and unconsciously attempt not to become aware of various emotional aspects of themselves, to avoid uncomfortable and perhaps painful feelings. This is a common phenomenon of human behavior. It is within the supportive and relaxed atmosphere of the group experience that such feelings can be recognized, acknowledged and replaced with conscious, uncontaminated choices in social behaviors and verbal attitudes. The courage to allow these kinds of meaningful connections to take place can help to resolve emotional conflicts and difficulties with feelings of mastery and empowerment.

Once the group members feel more trusting with the leader and other group members, channels of communication are opened, allowing for a genuine and profound sharing of emotional experiences to take place. Thus, feelings of trust and support as well as other identifying therapeutic factors assist in creating room for innovative and creative risk taking with in the group. For each individual the rewards of creating such a place that is their own can be a place that is very real and fully connected. It is a place to be fully who they are without the need to 'fit-in' to a pre-determined pattern.

In summary, being in an experiential process group all members has the opportunity for considerable personal gains, 'corrective emotional experiences' and 'intrapsychic' change that can last a lifetime. Just as individuals bring old learned behaviors and attitudes into the group they may take new ways of inter-relating outside the group. This may enable individuals to cultivate healthier interdependency with others, as well as increased expressions of mature and authentic intimacy.

References:  The Practice of Group Therapy. S.R. Slavson. International Universities Press, 1947 and Analytic Group Psychotherapy with Children, Adolescents and Adults. S.R. Slavson. Columbia University Press, 1964.

Author: Deborah Reeves, MGPGP, LPC, CGP Deborah Reeves is a licensed professional counselor and a certified specialist in group psychotherapy. She has a private clinical and consulting psychotherapy practice in Philadelphia, PA, and is a spokesperson/group leader for ANAD (National Association of Anorexia/Nervosa and Associated Disorders) for the Philadelphia Region. For additional information, visit her Web site at http://www.healing-minds.com

Reviewed by athealth on February 5, 2014.

This report updates and expands the Guidelines for Alzheimer's Disease Management (California Workgroup on Guidelines for Alzheimer's Disease Management, 2002), which itself was a revision of the California Workgroup's original Guideline published in 1998. All of these documents were based upon work begun by the Ad Hoc Standards of Care Committee of the Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs) of California (Hewett, Bass, Hart, Butrum, 1995) and were supported in part by the State of California, Department of Health Services, and the Alzheimer's Association, California Southland Chapter.

PURPOSE AND SCOPE

More than 5 million Americans now have Alzheimer's Disease (Alzheimer's Association, 2008), an increase of 25% since the previous version of this Guideline was published. Alzheimer's Disease destroys brain cells, causing problems with memory, thinking, and behavior severe enough to affect work, family and social relationships, and, eventually, the most basic activities of daily living. Alzheimer's Disease gets worse over time, it is incurable, and it is fatal. Today it is the seventh leading cause of death in the United States, and the fifth leading cause for individuals 65 and older (Alzheimer's Association).

Since the 2002 revision was completed, there has been an explosion of research in the field, generating new insights into the progression, treatment, and management of Alzheimer's Disease. The revised Guideline and this report are based in large part on a review of journal articles and meta-analyses published after 2001, incorporating the results of this tremendous body of new work.

Most older adults - including those with Alzheimer's Disease - receive their medical care from Primary Care Practitioners (PCPs) (Callahan et al., 2006), who may lack the information and other resources they need to treat this growing and demanding population (Reuben, Roth, Kamberg, Wenger, 2003). Nevertheless, PCPs should be able to provide or recommend a wide variety of services beyond medical management of Alzheimer's Disease and comorbid conditions, including recommendations regarding psychosocial issues, assistance to families and caregivers, and referral to legal and financial resources in the community. Many specialized services are available to help patients and families manage these aspects of AD, such as adult day services, respite care, and skilled nursing care, as well as helplines and outreach services operated by the Alzheimer's Association, Area Agencies on Aging, Councils on Aging, and Caregiver Resource Centers. This Guideline is intended to provide assistance to PCPs in offering comprehensive care to patients with Alzheimer's Disease and those who care for them over the course of their illness.

Because the Guideline is intended for use by PCPs who will encounter Alzheimer's Disease in the course of their work, we use the word "patients" throughout this report. However, it is important to recognize that the needs of people with Alzheimer's Disease and their families extend far beyond the realm of medical treatment, and that PCPs will be called upon to provide a wide spectrum of information and resources to assist them in dealing with this challenging, sometimes overwhelming condition.

NEW INFORMATION

The 2002 Guideline was written prior to the development and testing of some new pharmacological agents, as well as numerous non-pharmacological interventions designed to improve disease management and quality of life for both Alzheimer's Disease patients and their caregivers. Although some of these treatment methods were already in use, few were supported by evidence of efficacy from well-designed clinical trials. In many cases, this evidence now exists, and it is discussed in the current revision.

A notable advance in pharmacological treatment of Alzheimer's Disease was the introduction of memantine (Namenda) in October 2003, a year after release of the previous version of this Guideline. The first drug approved by the U.S. Food and Drug Administration (FDA) for treatment of moderate to severe Alzheimer's Disease, memantine has become an important component of treatment for many patients. The Treatment section includes two tables devoted to its use.

In the ensuing 6 years, additional emphasis on other topics relevant to the treatment of Alzheimer's Disease, along with the needs of patients and their families, has become apparent. These topics include, among others:

• the importance of cultural and linguistic factors in Alzheimer's Disease treatment;
• the conduct of legal capacity evaluations; and
• the special needs of early-stage and late-stage patients and their families

The revised report includes much new material regarding these critically important subjects, as well as updated references for many points discussed in previous versions.

NEW FORMAT

This version of the report also has been reformatted for convenience and ease of use, with appendices containing copies of many of the assessment instruments and forms cited in the text. Websites containing valuable resources for both PCPs and patients are included, and the online version of the report contains links to many of these resources.

As with the previous versions, the Guideline's recommendations themselves were designed to fit on one page for handy reference and organized by major care issues (assessment, treatment, patient and family education and support, and legal considerations). The revised and expanded report has been organized to conform to this layout. Each section deals with one of the four care issues and provides an overview of the issue, followed by the care recommendations and a review of the literature supporting them. The language used throughout the report reflects the strength of the supporting evidence, either "strong" (e.g., randomized clinical trial) or "moderate." In some instances, recommendations that are not evidence-based are nevertheless supported by expert opinion and Workgroup consensus, and are labeled as such.

View the full - Guideline for Alzheimer's Disease Management - Final Report 2008

See the updated NIH - Alzheimer's Diagnostic Guideline Validation

Source:

California Workgroup on Guidelines for Alzheimer's Disease Management
California Version © April 2008
Used with permission from the Alzheimer's Association of Los Angeles

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Reviewed by athealth on February 5, 2014.

What is Headache?

When a person has a headache, several areas of the head can hurt, including a network of nerves that extends over the scalp and certain nerves in the face, mouth, and throat. The muscles of the head and the blood vessels found along the surface and at the base of the brain are also sensitive to pain because they contain delicate nerve fibers. The bones of the skull and tissues of the brain itself never hurt because they lack pain-sensitive nerve fibers. The ends of these pain-sensitive nerves, called nociceptors, can be stimulated by stress, muscular tension, dilated blood vessels, and others triggers of headache.

Vascular headaches (migraines are a kind of vascular headache) are thought to involve abnormal function of the brain's blood vessels or vascular system; muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles; and traction and inflammatory headaches are symptoms of other disorders, ranging from brain tumor to stroke to sinus infection. Some types of headache are signals of more serious disorders: sudden, severe headache; headache associated with convulsions; headache accompanied by confusion or loss of consciousness; headache following a blow on the head; headache associated with pain in the eye or ear; persistent headache in a person who was previously headache free; recurring headache in children; headache associated with fever; headache that interferes with normal life. Physicians will obtain a full medical history and may order a blood test to screen for thyroid disease, anemia, or infections or x-rays to rule out a brain tumor or blood clots. CTs, MRIs, and EEGs may be recommended. An eye exam is usually performed to check for weakness in the eye muscle or unequal pupil size. Some scientists believe that fatigue, glaring or flickering lights, the weather, and certain foods may trigger migraine headaches.

Is there any treatment?

Not all headaches require medical attention. Some result from missed meals or occasional muscle tension and are easily remedied. If the problem is not relieved by standard treatments, a headache sufferer may be referred to an internist, a neurologist, or a psychologist. Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Regular exercise can also reduce the frequency and severity of migraine headaches. Temporary relief can sometimes be obtained by using cold pack or by pressing on the bulging artery found in front of the ear on the painful side of the head.

What is the prognosis?

About 90 percent of chronic headache patients can be helped.

What research is being done?

One theory of headaches is that people who suffer from severe headache and other types of chronic pain have lower levels of endorphins than people who are generally pain free. Thermography is an experimental technique for diagnosing headache. In thermography, an infrared camera converts skin temperature into a color picture, or thermogram, with different degrees of heat appearing as different colors. Researchers have found that thermograms of headache patients show strikingly different heat patterns from those of people who never or rarely get headaches.

Source: The National Institute of Neurological Disorders and Stroke

Reviewed by athealth on February 5, 2014.