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Nearly one-fifth of patients treated in general medical practices report drinking at levels considered "risky" or "hazardous" (1,2) and may be at risk for developing alcohol-related problems as a result. Brief intervention, which can be conducted in general health care settings, can help patients reduce that risk. Brief intervention is generally restricted to four or fewer sessions, each session lasting from a few minutes to 1 hour, and is designed to be conducted by health professionals who do not specialize in addictions treatment. It is most often used with patients who are not alcohol dependent, and its goal may be moderate drinking¹ rather than abstinence (4-6).

The content and approach of brief intervention vary depending on the severity of the patient's alcohol problem. Although the approaches used in brief intervention are similar for alcohol-dependent and non-alcohol-dependent patients, the goal of brief intervention for alcohol-dependent patients is abstinence. Most of the findings in this Alcohol Alert relate to the use of brief intervention with non-alcohol-dependent patients treated in general health care settings. However, brief intervention also has been used to motivate alcohol-dependent patients to enter specialized treatment with the goal of abstinence (7) and has been studied as an alternative to long-term treatment in specialized alcohol treatment settings (8,9). This Alcohol Alert explains the components of brief intervention and considers the effectiveness of this approach.

Screening for Alcohol Problems
A number of screening tools are available to identify current or potential alcohol problems among patients (see Alcohol Alert No. 8, "Screening for Alcoholism" [10]). Medical history questionnaires can pose questions about current and past alcohol use, including quantity and frequency of drinking (6). Questions about a patient's previous accidents and injuries can elicit clues to a potential alcohol problem (11). Several standardized screening questionnaires, such as the Alcohol Use Disorders Identification Test (AUDIT) (12), the CAGE (13), and the Michigan Alcoholism Screening Test (MAST) (14) and its derivatives (e.g., the Brief MAST [15]), can identify alcohol problems among current drinkers (16).² Laboratory tests, such as the test for the liver enzyme gamma-glutamyltransferase (GGT), may also reveal the presence of unsuspected alcohol problems (6).

Common Elements of Brief Intervention
Research indicates that brief intervention for alcohol problems is more effective than no intervention (e.g., 1,17-19) and often as effective as more extensive intervention (e.g., 4,8). To identify the key ingredients of brief intervention, Miller and Sanchez (20) proposed six elements summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy. The importance of these elements in enhancing effectiveness has been supported by further review (4). Goal setting, followup, and timing also have been identified as important to the effectiveness of brief intervention (5).

Feedback of Personal Risk.
Most health professionals delivering brief intervention provide patients with feedback on their risks for alcohol problems based on such factors as their current drinking patterns; problem indicators, such as laboratory test results; and any medical consequences of their drinking (1,17,21). For example, a physician may tell a patient that his or her drinking may be contributing to a current medical problem, such as hypertension, or may increase the risk for certain health problems (22).

Responsibility of the Patient.
Perceived personal control has been recognized to motivate behavior change (23). Therefore, brief intervention commonly emphasizes the patient's responsibility and choice for reducing drinking (e.g., 8). For example, a doctor or nurse may tell patients that "No one can make you change or make you decide to change. What you do about your drinking is up to you."

Advice To Change.
In some types of brief intervention, professionals give patients explicit advice to reduce or stop drinking (8,24). While expressing concern about the patient's current drinking and the related health risks, the physician may discuss guidelines for "low-risk" drinking (22).

Menu of Ways To Reduce Drinking.
Health professionals providing brief intervention may offer patients a variety of strategies from which to choose. These may include setting a specific limit on alcohol consumption; learning to recognize the antecedents of drinking and developing skills to avoid drinking in high-risk situations; planning ahead to limit drinking; pacing one's drinking (e.g., sipping, measuring, diluting, and spacing drinks); and learning to cope with the everyday problems that may lead to drinking (e.g., 19,25,26). Health care professionals often give their patients self-help materials to present such strategies and to help them carry these strategies out (e.g., 11,18,27,28). Self-help materials often include drinking diaries to help patients monitor their abstinent days and the number of drinks consumed on drinking days (e.g., 18,21), record instances when they are tempted to drink or experience social pressure to drink, and note the alternatives to drinking that they use (29). When working with alcohol-dependent patients, abstinence, rather than reduced drinking, is the goal of brief intervention.

Empathetic Counseling Style.
A warm, reflective, and understanding style of delivering brief intervention is more effective than an aggressive, confrontational, or coercive style (4). Miller and Rollnick (30) found that when they used an empathetic counseling style, patients' drinking was reduced by 77 percent, as opposed to 55 percent when a confrontational approach was used.

Self-Efficacy or Optimism of the Patient.
Health professionals delivering brief intervention commonly encourage patients to rely on their own resources to bring about change and to be optimistic about their ability to change their drinking behavior (e.g., 8,9). Brief intervention often includes motivation-enhancing techniques (e.g., eliciting and reinforcing self-motivating statements, such as "I am worried about my drinking and want to cut back," and emphasizing the patient's strengths) to encourage patients to develop, implement, and commit to plans to stop drinking (e.g., 9,31).

Establishing a Drinking Goal.
Patients are more likely to change their drinking behavior when they are involved in goal setting (30,32). The drinking goal usually is negotiated between the patient and physician and may be presented in writing as a prescription from the doctor or as a contract signed by the patient (e.g., 1).

Followup.
The health care professional continues to follow up on the patient's progress and provide ongoing support. Followup may take the form of telephone calls from office staff, repeat office visits, or repeat physical examinations or laboratory tests (e.g., 1,17,33).

Timing. Much of the research investigating the relationship between an individual's readiness to change and actual behavior change is based on studies of smoking cessation. Research findings have been applied to reducing drinking (5,6). Individuals are most likely to make behavior changes when they perceive that they have a problem (34,35) and when they feel they can change (36). Some patients may not be ready to change when brief intervention begins, but may be ready when they experience an alcohol-related illness or injury (34,35,37). Because a patient's readiness to change appears to be a significant predictor of changes in drinking behavior (38), it is important to assess patients' readiness to change when beginning a brief intervention. Rollnick and colleagues (39) created a 12-question "readiness to change" questionnaire for use in matching intervention techniques with a given patient's stage of readiness to change.

A few studies indicate that matching the type of brief intervention to the patient's readiness to change may be important. Among patients highly motivated to reduce their drinking and confident that they could change on their own, 77 percent decreased their drinking when given a self-help manual with specific instructions, compared with 28 percent who were given materials with only general advice (40). For patients with little motivation to change, Heather and colleagues (38) found that motivational interviewing was more effective than specific instructions.

Effectiveness of Brief Intervention

For non-alcohol-dependent patients.
Many studies suggest that brief intervention can help non-alcohol-dependent patients reduce their drinking (e.g., 1,17,18). In a meta-analysis of 32 brief intervention studies, Bien and colleagues (4) reported that the average positive change observed for intervention groups was about 27 percent. Positive changes were often observed for control groups, suggesting that the assessment of drinking behavior and related problems may, in itself, have led motivated patients to alter their drinking behavior.

For Alcohol-Dependent Patients.
Other studies have examined the effectiveness of brief intervention for motivating alcohol-dependent patients to enter long-term alcohol treatment. Among alcoholics identified in an emergency care setting, 65 percent of those receiving brief counseling kept a subsequent appointment for specialized treatment, compared with 5 percent of those who did not receive counseling (7).

Some studies conducted among alcohol-dependent patients have found that brief intervention is as effective as more extensive treatment approaches used in specialized alcohol treatment settings (8,9,41,42). Edwards and colleagues (8) compared the effectiveness of one session giving brief advice to stop drinking with standard alcohol treatment among 100 alcohol-dependent men. The brief advice emphasized personal responsibility to stop drinking and encouraged group members to return to work and improve their marriages. Group members also received a monthly followup telephone call. The group receiving standard alcohol treatment was admitted for an average of 3 weeks' inpatient alcoholism treatment, attended an average of ten 30-minute psychiatric outpatient counseling sessions, and received monthly followup visits. One year later, both groups reported a 40-percent decrease in alcohol-related problems. After 2 years, patients with less severe problems were more likely to report improvement if they received brief intervention than if they received intensive treatment. However, patients with more severe problems were more likely to report improvement if they received intensive treatment (43).

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) compared the effects of four 1-hour sessions of motivational enhancement therapy (MET) with 12 sessions of 12-step facilitation therapy and 12 sessions of cognitive-behavioral coping skills therapy in more than 1,500 alcohol-dependent patients (9). (Although MET can be considered a brief intervention because it consisted of only four sessions, it is more intensive than other brief interventions.) Both 1 year and 3 years after the intervention, participants in all three groups reported drinking less often and consuming fewer drinks per drinking day compared with their drinking behavior before treatment (9,42) (see Alcohol Alert No. 36, "Patient-Treatment Matching" [44]).

In summary, variations of brief intervention have been found effective for helping non-alcohol-dependent patients reduce or stop drinking, for motivating alcohol-dependent patients to enter long-term alcohol treatment, and for treating some alcohol-dependent patients.

Brief Intervention for Alcohol Problems--A Commentary by NIAAA Director Enoch Gordis, M.D.
The finding that brief intervention can be an effective means of intervening in alcohol problems adds an important tool to the clinician's repertoire of treatment options. It is an especially attractive option, because it can be used in primary care settings with minimum disruption to office routine and patient care. However, the evidence of its effectiveness and low cost may lead to the conclusion--particularly in today's managed-care environment--that it is always possible to substitute brief intervention for more specialized care. This would be a mistake. Brief intervention is not one therapy but several different types of treatment interventions, with differences in the types of patients who can benefit from it, the time required to administer the intervention, and the cost. Thus, requiring brief intervention in lieu of other types of therapy without specifying the type of intervention or the patients for whom it is best suited might help some, but certainly not all, patients with alcohol problems.

References
(1) Fleming, M.F.; Barry, K.L.; Manwell, L.B.; Johnson, K.; and London, R. Brief physician advice for problem alcohol drinkers: A randomized trial in community-based primary care practices. Journal of the American Medical Association 277(13):1039-1045, 1997.

(2) Fleming, M.F.; Manwell, L.B.; Barry, K.L.; and Johnson, K. At-risk drinking in an HMO primary care sample: Prevalence and health policy implications. American Journal of Public Health 88(1):90-93, 1998.

(3) U.S. Department of Agriculture and the U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed. Washington, DC: U.S. Department of Agriculture, U.S. Department of Health and Human Services, 1995.

(4) Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review. Addiction 88(3):315-336, 1993.

(5) Graham, A.W., and Fleming, M.S. Brief interventions. In: Graham, A.W.; Schultz, T.K.; and Wilford, B.B., eds. Principles of Addiction Medicine. 2d ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc., 1998. pp. 615-630.

(6) O'Connor, P.G., and Schottenfeld, R.S. Patients with alcohol problems. New England Journal of Medicine 338(9):592-602, 1998.

(7) Chafetz, M.E.; Blane, H.T.; Abram, H.S.; Golner, J.; Lacy, E.; McCourt, W.F.; Clark, E.; and Meyers, W. Establishing treatment relations with alcoholics. Journal of Nervous and Mental Disease 134(5):395-409, 1962.

(8)Edwards, G.; Orford, J.; Egert, S.; Guthrie, S.; Hawker, A.; Hensman, C.; Mitcheson, M.; Oppenheimer, E.; and Taylor, C. Alcoholism: A controlled trial of "treatment" and "advice." Journal of Studies on Alcohol 38(5):1004-1031, 1977.

(9) Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol 58(1):7-29, 1997.

(10) National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert No. 8, "Screening for Alcoholism." Rockville, MD: the Institute, 1990.

(11) Israel, Y.; Hollander, O.; Sanchez-Craig, M.; Booker, S.; Miller, V.; Gingrich, R.; and Rankin, J.G. Screening for problem drinking and counseling by the primary care physician-nurse team. Alcoholism: Clinical and Experimental Research 20(8):1443-1450, 1996.

(12) Babor, T.F.; De La Fuente, J.R.; Saunders, J.; and Babor, M. AUDIT: The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Health Care. Geneva: World Health Organization, 1989.

(13) Ewing, J.A. Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association 252(14):1905-1907, 1984.

(14) Selzer, M.L. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 127(12):89-94, 1971.

(15) Pokorny, A.D.; Miller, B.A.; and Kaplan, H.B. The brief MAST: A shortened version of the Michigan Alcoholism Screening Test. American Journal of Psychiatry 129(3):118-121, 1972.

(16) Allen, J.P.; Maisto, S.A.; and Connors, G.J. Self-report screening tests for alcohol problems in primary care. Archives of Internal Medicine 155(16):1726-1730, 1995.

(17) Kristenson, H.; Öhlin, H.; Hultén-Nosslin, M.-B.; Trell, E.; and Hood, B. Identification and intervention of heavy drinking in middle-aged men: Results and follow-up of 24-60 months of long-term study with randomized controls. Alcoholism: Clinical and Experimental Research 7(2):203-209, 1983.

(18) Wallace, P.; Cutler, S.; and Haines, A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal 297(6649):663-668, 1988.

(19) World Health Organization (WHO) Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. American Journal of Public Health 86(7):948-955, 1996.

(20) Miller, W.R., and Sanchez, V.C. Motivating young adults for treatment and lifestyle change. In: Howard, G., ed. Issues in Alcohol Use and Misuse in Young Adults. Notre Dame, IN: University of Notre Dame Press, 1993.

(21) Heather, N.; Campion, P.D.; Neville, R.G.; and Maccabe, D. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme). Journal of the Royal College of General Practitioners 37(301):358-363, 1987.

(22) National Institute on Alcohol Abuse and Alcoholism. The Physicians' Guide to Helping Patients With Alcohol Problems. NIH Publication No. 95-3769. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, 1995.

(23) Miller, W.R. Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin 98(1):84-107, 1985.

(24) Orford, J., and Edwards, G. Alcoholism. Oxford, England: Oxford University Press, 1977.

(25) Sanchez-Craig, M. Random assignment to abstinence or controlled drinking in a cognitive-behavioral program: Short-term effects on drinking behavior. Addictive Behaviors 5(1):35-39, 1980.

(26) Sanchez-Craig, M.; Spivak, K.; and Davila, R. Superior outcome of females over males after brief treatment for the reduction of heavy drinking: Replication and report of therapist effects. British Journal of Addiction 86(7):867-876, 1991.

(27) Anderson, P., and Scott, E. The effect of general practitioners' advice to heavy drinking men. British Journal of Addiction 87(6):891-900, 1992.

(28) Chick, J.; Lloyd, G.; and Crombie, E. Counselling problem drinkers in medical wards: A controlled study. British Medical Journal 290(6473):965-967, 1985.

(29) Sanchez-Craig, M. Brief didactic treatment for alcohol and drug-related problems: An approach based on client choice. British Journal of Addiction 85(2):169-177, 1990.

(30) Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.

(31) Burge, S.K.; Amodei, N.; Elkin, B.; Catala, S.; Andrew, S.R.; Lane, P.A.; and Seale, J.P. An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients. Addiction 92(12):1705-1716, 1997.

(32) Ockene, J.K.; Quirk, M.E.; Goldberg, R.J.; Kristeller, J.L.; Donnelly, G.; Kalan, K.L.; Gould, B.; Greene, H.L.; Harrison-Atlas, R.; Pease, J.; Pickens, S.; and Williams, J.W. A residents' training program for the development of smoking intervention skills. Archives of Internal Medicine 148(5):1039-1045, 1988.

(33) Persson, J., and Magnusson, P.H. Early intervention in patients with excessive consumption of alcohol: A controlled study. Alcohol 6(5):403-408, 1989.

(34) DiClemente, C.C.; Fairhurst, S.K.; Velasquez, M.M.; Prochaska, J.O.; Velicer, W.F.; and Rossi, J.S. The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology 59(2):295-304, 1991.

(35) Prochaska, J.O., and DiClemente, C.C. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51(3):390-395, 1983.

(36) Bandura, A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977.

(37) DiClemente, C.C., and Hughes, S.O. Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse 2(2):217-235, 1990.

(38) Heather, N.; Rollnick, S.; and Bell, A. Predictive validity of the Readiness to Change Questionnaire. Addiction 88(12):1667-1677, 1993.

(39) Rollnick, S.; Heather, N.; Gold, R.; and Hall, W. Development of a short "readiness to change" questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction 87(5):743-754, 1992.

(40) Spivak, K; Sanchez-Craig, M.; and Davila, R. Assisting problem drinkers to change on their own: Effect of specific and non-specific advice. Addiction 89(9):1135-1142, 1994.

(41) Edwards, G.; Duckitt, A.; Oppenheimer, E.; Sheehan, M.; and Taylor, C. What happens to alcoholics? Lancet 2(8344):269-270, 1983.

(42) Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research 22(6):1300-1311, 1998.

(43) Orford, J.; Oppenheimer, E.; and Edwards, G. Abstinence or control: The outcome for excessive drinkers two years after consultation. Behavior Research and Therapy 14:409-418, 1976.

(44) National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert No. 36, "Patient-Treatment Matching." Bethesda, MD: the Institute, 1997.

¹The U.S. Department of Agriculture and the U.S. Department of Health and Human Services define moderate drinking as no more than two drinks per day for men and no more than one drink per day for women. A standard drink is 12 grams of pure alcohol, which is equal to one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits (3).

²These and other instruments are available on NIAAA's Web site

Source: National Institute on Alcohol Abuse and Alcoholism
Alcohol Alert No. 43

Reviewed by athealth on January 31, 2014

Building Self-Esteem: A Self-Help Guide - Contents:

1. Feelings of low self-esteem
2. Self-esteem and depression
3. Raise your self-esteem
4. Changing negative thoughts
5. Activities that build self-esteem

Low Self-Esteem

Most people feel bad about themselves from time to time. Feelings of low self-esteem may be triggered by being treated poorly by someone else recently or in the past, or by a person's own judgments of him or herself. This is normal. However, low self-esteem is a constant companion for too many people, especially those who experience depression, anxiety, phobias, psychosis, delusional thinking, or who have an illness or a disability. If you are one of these people, you may go through life feeling bad about yourself needlessly. Low self-esteem keeps you from enjoying life, doing the things you want to do, and working toward personal goals.

You have a right to feel good about yourself. However, it can be very difficult to feel good about yourself when you are under the stress of having symptoms that are hard to manage, when you are dealing with a disability, when you are having a difficult time, or when others are treating you badly. At these times, it is easy to be drawn into a downward spiral of lower and lower self-esteem. For instance, you may begin feeling bad about yourself when someone insults you, you are under a lot of pressure at work, or you are having a difficult time getting along with someone in your family. Then you begin to give yourself negative self-talk, like "I'm no good." That may make you feel so bad about yourself that you do something to hurt yourself or someone else, such as getting drunk or yelling at your children. By using the ideas and activities in this guide, you can avoid doing things that make you feel even worse and do those things that will make you feel better about yourself.

This guide will give you ideas on things you can do to feel better about yourself and to raise your self-esteem. The ideas have come from people like yourself, people who realize they have low self-esteem and are working to improve it.

As you begin to use the methods in this guide and other methods that you may think of to improve your self-esteem, you may notice that you have some feelings of resistance to positive feelings about yourself. This is normal. Don't let these feelings stop you from feeling good about yourself. They will diminish as you feel better and better about yourself. To help relieve these feelings, let your friends know what you are going through. Have a good cry if you can. Do things to relax, such as meditating or taking a nice warm bath.

As you read this guide and work on the exercises, keep the following statement in mind:

"I am a very special, unique, and valuable person. I deserve to feel good about myself."

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

What is bulimia?

Bulimia is the shortened term for an eating disorder called bulimia nervosa.

What characteristics are associated with bulimia?

A person with bulimia usually engages in episodes of binge eating followed by the purging methods he/she has devised to prevent weight gain. The bulimic attempts to rid the body of the ingested food by purging. Purging takes the form of self-induced vomiting, the use of diuretics (water pills), or the heavy use of laxatives.

There is also a nonpurging type of bulimia. The person with the nonpurging type of bulimia will fast for prolonged periods or exercise intensely to keep from gaining weight. The bulimic is often concerned about body shape and has an intense fear of weight gain. Therefore, the characteristics associated with bulimia include binge eating followed by attempts to keep from gaining weight. Binge eating is described as the ingestion of excessive amounts of high caloric food. When bulimics binge, they feel out of control, and their serious attempt to keep from gaining weight by purging offers them a form of control. Following an episode of binge eating, bulimics may totally stop eating and fast for a day or more.

Are there genetic factors associated with bulimia?

Yes, people with bulimia occasionally have close relatives who have eating disorders. Also, relatives of bulimics may abuse substances such as alcohol or have mood disorders like depression.

Does bulimia affect males, females, or both?

Very few males suffer from bulimia. Over 90% of bulimia is found in females.

At what age does bulimia appear?

Bulimia usually begins in adolescence or the early adult years.

How often is bulimia seen in our society?

About two (2) out of every one hundred (100) adolescent girls have some form of bulimia.

How is bulimia diagnosed?

Frequently, the bulimic attempts to hide her abnormal eating patterns. Family members, friends, or medical care givers may suspect an eating disorder and encourage the bulimic to seek professional help.

A mental health professional may diagnose bulimia by taking a careful personal history from the client/patient. It is important to the therapist to learn the details of that person's life. It is also very important not to overlook a physical illness that might mimic or contribute to this psychological disorder.

The diagnosis of bulimia is made when the history reveals that the person eats a large quantity of food within a two hour period which is followed by a sense of lack of control. The person then tries to prevent weight gain by inducing vomiting, overusing laxatives, using diuretics, and/or enemas. The person may also engage in fasting or excessive exercise. Also, the person with suspected bulimia will be overly concerned about body shape and weight. In order to make a diagnosis of bulimia, this behavior must occur at least twice a week for a period of three months.

How is bulimia treated?

Bulimia is often treated by helping the individual establish a healthy body concept and learn correct eating habits. Usually this is accomplished through therapy which includes an educational focus. Part of that education emphasizes the destructive nature of the bingeing and purging pattern.

A cognitive behavior approach, group therapy, family therapy, and/or the use of medications may be used. Most patients with bulimia can be treated as outpatients.

What happens to someone with bulimia?

Unfortunately, there have been no long term studies focusing on the course of bulimia. We know that it is not unusual for people with bulimia to have periods of remission. Some of the complications associated with bulimia include inflammation of the esophagus and dental cavities which are caused by repeated vomiting.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Reviewed  by athealth on January 31, 2014

Bullies

1. Types of bullies
2. Types of bully victims
3. Types of bully bystanders

"He gave me that look, you know? Like, 'Hey, who do you think you are?' I thought this kid needs to find out right now who's in charge around here."

In a 1978 study, Olweus described three different types of bully:

• the aggressive bully
• the passive bully
• the bully-victim.

These characterizations still hold true today.

Aggressive bullies are the most common type of bully.

Young people who fall into this category tend to be physically strong, impulsive, hot-tempered, belligerent, fearless, coercive, confident, and lacking in empathy for their victims. They have an aggressive personality and are motivated by power and the desire to dominate others. They are also likely to make negative attributions, often seeing slights or hostility in those around them where neither actually exists. According to Olweus, the aggressive bully tends to be most popular in the early school years and then less so in the upper grades - perhaps because young children are more likely than older students to admire the macho image. As students get older, they become better able to think critically about peers and "leaders."

Surprisingly Skilled

In contrast to the popular notion that bullies lack social skills, research has shown that bullies are actually quite adept at reading social cues and perspective-taking. Rather than using these skills prosocially, such as to empathize with others, they instead use them to identify and prey on peer vulnerabilities.

"All data point in the same direction - that bullies have no problem with self-esteem."  - Dan Olweus, 2002 OSDFS NationalTechnical Assistance Meeting

Passive bullies, unlike the ultra-confident aggressive bullies, tend to be insecure.

They are also much less popular than the aggressive bullies and often have low-self esteem, few likable qualities, and unhappy home lives. Passive bullies also appear to have difficulties concentrating and focusing their attention at school, as well as violent outbursts or temper tantrums that lead to problems with their peers. Rather than initiating a bullying interaction, passive bullies tend to hang back until one is already under way, usually at the instigation of an aggressive bully. Once a bullying incident begins, passive bullies become enthusiastic participants. In fact, passive bullies are very quick to align themselves with and display intense loyalty to the more powerful aggressive bullies. Some researchers refer to this group as anxious bullies.

Bully-victims represent a small percentage of bullies who have been seriously bullied themselves.

Bully-victims are often physically weaker than those who bully them but are almost always physically stronger than their own victims. They possess some of the same characteristics as provocative victims (described below); they are easily aroused and sometimes provoke others who are clearly weaker than they are. Bully-victims are generally unpopular with their peers, and they are more likely than other types of bullies to be both anxious and depressed.
Dieter Wolke, of the University of Hertfordshire, England, identified a fourth group of bullies: pure bullies. "It appears that pure bullies are healthy individuals, who enjoy school and use bullying to obtain dominance," says Wolke, who labels these children "cool operators." Pure bullies have not been victimized themselves, and they are rarely absent from school -- presumably because they enjoy victimizing their peers.

Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.
Adapted from Exploring the Nature and Prevention of Bullying

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

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Page last modified or reviewed by At Health on January 31, 2013

 

A recent study in the Journal of the American Medical Association demonstrated the seriousness of bullying in American schools. In a nationally representative sample of over 15,686 students in the United States (grades 6 through 10), 29.9% self-reported frequent involvement in bullying at school, with 13% participating as a bully, 10.9% as a victim, and 6% as both (Nansel et al., 2001). Aggression and violence during childhood and adolescence have been the focus of much research over the past several decades (e.g., Loeber & Hay, 1997; Olweus, 1979). These researchers have found that serious forms of aggression remain relatively stable from childhood through adulthood; however, Loeber and Hay (1997) argue that mild forms of aggression may not begin for some children until early or late adolescence. Despite Loeber and Hay's findings, very little research has been conducted on mild forms of aggression, such as bullying, during the middle years. One notable gap in the evolving literature on bullying and victimization during early adolescence is the role that peers play in promoting bullying and victimization by either reinforcing the aggressor, failing to intervene to stop the victimization, or affiliating with students who bully. This digest looks at the limited research available on the role of the peer group in bullying to learn more about how bullying and victimization might emerge or continue during early adolescence.

Definitions of Bullying

While definitions of bullying often differ semantically, many of them have one concept in common: Bullying is a subtype of aggression (Dodge, 1991; Olweus, 1993; Smith & Thompson, 1991). The following definitions are common in the literature: "A person is being bullied when he or she is exposed, repeatedly over time, to negative actions on the part of one or more other students" (Olweus, 1993, p. 9). "A student is being bullied or picked on when another student says nasty and unpleasant things to him or her. It is also bullying when a student is hit, kicked, threatened, locked inside a room, sent nasty notes, and when no one ever talks to him" (Smith & Sharp, 1994, p. 1).

Peer Acceptance and Status

During early adolescence, the function and importance of the peer group change dramatically (Crockett, Losoff, & Petersen, 1984; Dornbusch, 1989). Adolescents, seeking autonomy from their parents, turn to their peers to discuss problems, feelings, fears, and doubts, thereby increasing the salience of time spent with friends (Sebald, 1992; Youniss & Smollar, 1985). However, this reliance on peers for social support is coupled with increasing pressures to attain social status (Corsaro & Eder, 1990; Eder, 1985). It is during adolescence that peer groups become stratified and issues of acceptance and popularity become increasingly important. Research indicates, for example, that toughness and aggressiveness are important status considerations for boys, while appearance is a central determinant of social status among girls (Eder, 1995). Some researchers believe that the pressure to gain peer acceptance and status may be related to an increase in teasing and bullying. This behavior may be intended to demonstrate superiority over other students for boys and girls, either through name-calling or ridiculing.

Setting the Stage for Bullying in Middle School

Research with elementary school children in other countries supports the view that peer group members reinforce and maintain bullying (e.g., Craig & Pepler, 1997; Salmivalli et al., 1996). These authors contend that bullying can best be understood from a social-interactional perspective (i.e., bullying behaviors are considered a result of a complex interaction between individual characteristics, such as impulsivity, and the social context, including the peer group and school social system). Participation of peers in the bullying process was clearly evident when Pepler and her colleagues videotaped aggressive and socially competent Canadian children in grades 1 through 6 on the playground; peers were involved in bullying in an astounding 85% of bully episodes (Craig & Pepler, 1997). Similarly, in a survey study of sixth-graders in Finland, the majority of students participated in the bullying process in some capacity, and their various participant roles were significantly related to social status within their respective classrooms (Salmivalli et al., 1996). Clearly, peers play an instrumental role in bullying and victimization on elementary school playgrounds and within classrooms.

Athealth.com Sidebar: There appears to be a link between ADHD and bullying. A 2008 study conducted in Sweden, showed that children with ADHD are four times more likely than their peers to bully other children, and they are almost ten times as likely than other children to be bullied.

Transition to Middle School and "Fitting In"

Less well understood are the peer dynamics associated with bullying during the transition from elementary school to middle school. Some researchers speculate that this transition can cause stress that might promote bullying behavior, as students attempt to define their place in the new social structure. For example, changing from one school to another often leads to an increase in emotional and academic difficulties (Rudolph et al., 2001); bullying may be another way that young people deal with the stress of a new environment.

A short-term investigation of over 500 middle school students (grades 6-8) found an increase in bullying behavior among sixth-graders over a 4-month period (Espelage, Bosworth, & Simon, 2001). The authors speculated that the sixth-graders were assimilating into the middle school, where bullying behavior was part of the school culture. This speculation is supported by the theory that bullying is a learned behavior, and that as they enter middle school, sixth-graders have not yet learned how to interact positively in the social milieu of the school. Many sixth-graders who wish to "fit in" may adopt the behaviors--including teasing--of those students who have been in the school longer and who have more power to dictate the social norm.

Two recent studies further examined the hypothesis that middle school students opt to bully their peers to "fit in" (Pellegrini, Bartini, & Brooks, 1999; Rodkin et al., 2000). Pellegrini and colleagues found that bullying enhanced within-group status and popularity among 138 fifth-graders making the transition through the first year of middle school. Similarly, Rodkin and colleagues, in a study of 452 fourth- through sixth-grade boys, found 13.1% were rated as both aggressive and popular by their teachers. Furthermore, these aggressive popular boys and popular prosocial boys received an equivalent number of "cool" ratings from peers.

These two studies do not examine how the influence of the peer group on bullying behaviors differs across sex, grade, or level of peer group status. A study by Espelage and Holt (2001) of 422 middle school students (grades 6-8), using a survey that included demographic questions, self-report, and peer-report measures of bullying and victimization, and measures of other psychosocial variables, examined the association between popularity and bullying behavior. Despite the finding that bullies as a group enjoyed a strong friendship network, the relationship between bullying and popularity differed for males and females, and also differed across grades. The most striking finding was the strong correlation between bullying and popularity among sixth-grade males, which dropped considerably for seventh-grade males and was not associated for eighth-grade males. Closer examination of peer cliques in this sample found that students not only "hung out" with peers who bully at similar rates but that students also reported an increase in bullying over a school year if their primary peer group bullied others (Espelage, Holt, & Henkel, in press).

Conclusion

We cannot assume that bullying among young adolescents is a simple interaction between a bully and a victim. Instead, recent studies and media reports suggest that there are groups of students who support their peers and sometimes participate in teasing and harassing other students. It seems important for families, schools, and other community institutions to help children and young adolescents learn how to manage, and potentially change, the pressure to hurt their classmates in order to "fit in."

References

Corsaro, W. A., & Eder, D. (1990). Children's peer cultures. Annual Review of Sociology, 16, 197-220.

Craig, W. M., & Pepler, D. J. (1997). Observations of bullying and victimization in the school yard. Canadian Journal of School Psychology, 13, 41-59.

Crockett, L., Losoff, M., & Petersen, A. C. (1984). Perceptions of the peer group and friendship in early adolescence. Journal of Early Adolescence, 4(2), 155-181.

Dodge, K. A. (1991). The structure and function of reactive and proactive aggression. In D. J. Pepler & K. H. Rubin (Eds.), The development and treatment of childhood aggression (pp. 201-216). Hillsdale, NJ: Erlbaum.

Dornbusch, S. M. (1989). The sociology of adolescence. Annual Review of Sociology, 15, 233-259.

Eder, D. (1985). The cycle of popularity: Interpersonal relations among female adolescents. Sociology of Education, 58(3), 154-165. EJ 322 823.

Eder, D. (1995). School talk: Gender and adolescent culture. New Brunswick, NJ: Rutgers University Press. ED 388 393.

Espelage, D. L., Bosworth, K., & Simon, T. S. (2001). Short-term stability and change of bullying in middle school students: An examination of demographic, psychosocial, and environmental correlates. Violence and Victims, 16(4), 411-426.

Espelage, D. L., & Holt, M. K. (2001). Bullying and victimization during early adolescence: Peer influences and psychosocial correlates (pp. 123-142). Binghamton, NY: Haworth Press.

Espelage, D. L., Holt, M. K., & Henkel, R. R. (in press). Examination of peer group contextual effects on aggression during early adolescence. Child Development.

Loeber, R., & Hay, D. (1997). Key issues in the development of aggression and violence from childhood to early adulthood. Annual Review of Psychology, 48, 371-410.

Nansel, T. R., Overpeck, M., Pilla, R. S., Ruan, W. J., Simons-Morton, B., & Scheidt, P. (2001). Bullying behaviors among U.S. youth: Prevalence and association with psychosocial adjustment. Journal of the American Medical Association, 285(16), 2094-2100.

Olweus, D. (1979). Stability of aggressive reaction patterns in males: A review. Psychological Bulletin, 86(4), 852-875. EJ 216 558.

Olweus, D. (1993). Bully/victim problems among schoolchildren: Long-term consequences and an effective intervention program. In S. Hodgins, Mental disorder and crime (pp. 317-349). Thousand Oaks, CA: Sage.

Pellegrini, A. D. (2002). Bullying, victimization, and sexual harassment during the transition to middle school. Educational Psychologist, 37(3), 151-164.

Pellegrini, A. D., Bartini, M., & Brooks, F. (1999). School bullies, victims, and aggressive victims. Factors relating to group affiliation and victimization in early adolescence. Journal of Educational Psychology, 91(2), 216-224.

Rodkin, P. C., Farmer, T. W., Pearl, R., & Van Acker, R. (2000). Heterogeneity of popular boys: Antisocial and prosocial configurations. Developmental Psychology, 36(1), 14-24. EJ 602 204.

Rudolph, K. D., Lambert, S. F., Clark, A. G., & Kurlakowsky, K. D. (2001). Negotiating the transition to middle school: The role of self-regulatory processes. Child Development, 72(3), 929-946. EJ 639 740.

Salmivalli, C., Lagerspetz, K., Bjorkqvist, K., Osterman, K., & Kaukiainen, A. (1996). Bullying as a group process: Participant roles in their relations to social status within the group. Aggressive Behavior, 22(1), 1-15.

Sebald, H. (1992). Adolescence. Upper Saddle River, NJ: Prentice Hall.

Smith, P. K., & Sharp, S. (Eds.). (1994). School bullying: Insights and perspectives. London: Routledge.

Smith, P. K., & Thompson, D. (1991). Practical approaches to bullying. London: David Fulton.

Youniss, J., & Smollar, J. (1985). Adolescent relations with mothers, fathers, and friends. Chicago: University of Chicago Press.

Source: ERIC Clearinghouse on Elementary and Early Childhood Education
November 2002
Author: Dorothy L. Espelage, PhD

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

Tips for Implementing Bullying Prevention Activities

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

Support and Participation of School Leaders

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

Staff Training and Support

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

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

Parent and Community Involvement

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

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

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

Anti-Bullying Policies

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

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

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

Supervision and Intervention

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

Skill-Building Among Students

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

Resources for Bullies, Victims, and Families

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

Athealth.com Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Source: Adapted from Exploring the Nature and Prevention of Bullying

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

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

Bullying

1. What is bullying?
2. How common is bullying?
3. Where does bullying occur?
4. What influences bullying?

What Is Bullying?

Nearly every publication on the topic of bullying presents its own definition of the problem. Separated by primarily semantic differences, the majority of definitions proposed by researchers and practitioners incorporate the following key concepts:

• Bullying involves intentional, and largely unprovoked, efforts to harm another.
• Bullying can be physical or verbal, and direct or indirect in nature.
• Bullying involves repeated negative actions by one or more against another.
• Bullying involves an imbalance of physical or psychological power.

In her book Childhood Bullying, Teasing, and Violence: What School Personnel, Other Professionals, and Parents Can Do (Second Edition), Dorothea Ross - cofounder of the Society of Pediatric Psychology and research psychologist at Stanford Medical School - reviews many of the different conceptualizations of bullying used by researchers over the years.

Ross then proposes the following definition of bullying, which represents a synthesis of the varied definitions presented in the bullying literature:

Bullying refers to intentional and generally unprovoked attempts by one or more individuals to inflict physical hurt and/or psychological distress on one or more victims. There must be an imbalance of physical or psychological power, with the bully actually being stronger or perceived to be stronger than the victim. The bullying may be direct, with face-to-face physical or verbal confrontations, or indirect, with less visible actions such as spreading rumors or social exclusion. Although a single attack on a victim if severe enough can be accurately described as bullying, the term more often refers to a series of negative actions that occur frequently over time."

In addition to presenting her own definition, Ross also reviews some of the obstacles that impede consensus among researchers on the definition of bullying. Specifically, there are some disagreements about whether bullying must involve repeated attacks and an imbalance of power. Consider the following:

• Repeated attacks: Many people believe that a behavior that occurs just once or twice, no matter how serious, should not be considered bullying. One persuasive argument for this has to do with the notion that bullying leads to two kinds of distress among victims: the immediate physical or psychological distress that results from the actual bullying incident and the anticipatory fear that often occurs from the spoken or implied threat of future attacks. However, others contend that attacks should not have to occur repeatedly and over time to be classified as bullying. Perhaps the most compelling argument for this perspective comes from children themselves. In an unpublished survey, respondents ranging in age from 5 to 20 years did not think that negative actions had to be repeated to be considered bullying.
• Imbalance of power: Most people agree that bullying involves an imbalance of physical or psychological power, either real or perceived, between the aggressor and the victim; however, Thompson and Smith (1991) questioned this based on conversations they had with children who labeled as bullying any situation involving unprovoked aggression, even when the odds seemed to be even.

It is interesting to note that these two problems with definition seem to result from differences in the ways that adults and children conceptualize bullying. Researchers and practitioners alike will need to investigate these differences to better understand and more effectively address the problem of bullying in the future.

While the definition of bullying presented above alludes to different types of bullying behaviors, the following is a breakdown of four distinct categories:

Physical Bullying
Includes punching, poking, strangling, hair pulling, beating, biting, and excessive tickling.

Emotional Bullying
Includes rejecting, extorting, defaming, humiliating, blackmailing, manipulating friends, isolating, ostracizing, and peer pressure.

Sexual Bullying
Includes exhibitionism, voyeurism, sexual propositioning, sexual harassment, and abuse involving physical contact and assault.

Verbal Bullying
Includes such acts as hurtful name-calling, teasing, and gossip.

Within each of these categories, specific bullying behaviors can occur at different levels of severity. While all bullying is unacceptable, many of the more serious behaviors are actually illegal. Over the past two decades, severe school bullying has been increasingly acknowledged to fall under the rubric of criminal behavior. In 1987, during a meeting held at Harvard University to discuss the problem of school bullying, an international group of scholars made the following statement:

"Under the euphemism of 'bullying,' we see a much broader, more serious affair. We see instances of assault and battery, gang activity, threat of bodily harm, weapons possession, extortion, civil rights violations, attempted murder, and murder.

"Everybody knows these are crimes. The fact that they were committed by minors upon minors does not make them less than crimes. The fact that they were committed on school grounds by students does not make them less than crimes."

It is important to understand that bullying exists at multiple levels, and that behaviors at each level of severity must be taken seriously - because any and all bullying is harmful, and because bullies can easily progress from less to more severe bullying.

Athealth.com Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.Source: Adapted from Exploring the Nature and Prevention of Bullying

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

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

Next Page

 

As the U.S. population ages, more people are faced with the responsibility of caring for elderly loved ones with Alzheimer's disease, cancer, or other health problems. Many parents are also raising children with severe disabilities at home. More often today, these caregivers are continuing to care for children with disabilities well into their adulthood.

The people needing care often need help with basic daily tasks. Caregivers help with a wide range of activities, including:

• cooking
• feeding
• giving medicine
• bathing
• running errands

People who do not get paid for providing care are known as informal caregivers or family caregivers. Most informal caregivers are women. Often, these women also have children to take care of and jobs outside the home.

Being an informal caregiver can have many rewards. It can give you a feeling of giving back to a loved one. It can make you feel needed and can lead to a stronger relationship with the person receiving care. However, caregiving can also take a toll on your mental and physical health.

What is caregiver stress?

Caregiver stress is the emotional strain of caregiving. It can take many forms. For instance, you may feel frustrated and angry taking care of someone with dementia (dih-MEN-chuh) who often wanders away or becomes easily upset. Or you may feel guilty because you think that you should be able to provide better care, despite all the other things that you have to do.

How can I tell if caregiving is putting too much stress on me?

Caregiving may be putting too much strain on you if you have any of the following symptoms:

• sleeping too much or too little
• gain or loss of a lot of weight
• feeling tired most of the time
• loss of interest in activities you used to enjoy
• becoming easily irritated or angered
• often feeling sad
• frequent headaches, bodily pain, or other physical problems
• abuse of alcohol or drugs, including prescription drugs

Talk to a counselor, psychologist, or other mental health professional right away if your stress leads you to physically or emotionally harm the person you are caring for.

How can caregiver stress affect my health?

Research shows that, compared with noncaregivers, caregivers:

• are more likely to have symptoms of depression or anxiety
• are more likely to have heart disease, cancer, diabetes, and arthritis
• have a weaker immune response, which can lead to frequent infections and increased risk of cancers
• have higher levels of obesity
• may be at higher risk of mental decline, including problems with memory and paying attention

What can I do to prevent or relieve stress?

First, never dismiss your feelings as "just stress." Caregiver stress can lead to serious health problems and you should take steps to reduce it as much as you can. Tips for reducing caregiver stress:

• Ask for and accept help.
• Say "no" to requests that are draining, such as hosting holiday meals.
• Stay in touch with family and friends.
• Join a caregiver support group.
• Attend a class to learn how to take care of someone with the disease that your loved one has.
• Prioritize, make lists, and establish a daily routine.
• Set realistic goals for each day.
• Get an annual medical checkup.
• Stay active, eat a healthy diet, and try to get enough sleep.

What caregiving services can I find in my community?

Caregiving services include:

• transportation
• meal delivery
• home health care services (such as nursing or physical therapy)
• nonmedical home care services (such as housekeeping or cooking)
• home modification (changes to the home that make it easier for your loved one to perform basic daily tasks, such as bathing, using the toilet, and moving around)
• legal and financial counseling

What can I do if I need a break?

Taking some time off from caregiving can reduce stress. "Respite care" provides substitute caregiving to give the regular caregiver a much-needed break. Respite care may be provided by:

• home health care workers
• adult day-care centers
• short-term nursing homes

How do I find out about caregiving services in my community?

Contact your local Area Agency on Aging (AAA) to learn about caregiving services where you live. AAAs are usually listed in the city or county government sections of the telephone directory under "Aging" or "Health and Human Services." The National Eldercare Locator, a service of the U.S. Administration on Aging, can also help you find your local AAA.

Resources:

Administration on Aging
www.aoa.gov
www.eldercare.gov
Eldercare Locator: (800) 677-1116

Family Caregiver Alliance
www.caregiver.org

Adapted from The Healthy Woman: A Complete Guide for All Ages
Chapter on Mental Health
U.S. Department of Health and Human Services, Office on Women's Health 2008

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

Living on the edge: Baby boomers faced with caregiving dilemma

By Karen Orloff Kaplan and Ira Byock

Beth Liebich can't pinpoint the day she officially became a caregiver.

Maybe it began in 1995 with her mother's intestinal inflammation. There were the twice-monthly doctor visits and extra trips to the pharmacy and the nearly hour commute across town - from her home in Clifton Park, N.Y., to Saratoga Springs and back - to check on Mom during the week. Things heated up when her father and father-in-law each had cardiac valve replacement surgery in Boston within two weeks of one another.

By 1998 she thought nothing of dropping off her mother at the cardiologist's office, then swinging by to pick up her father-in-law for his ophthalmology or cardiology appointment, making it back in time to hear what Mom's heart doctor had to say.

In 2000, both her mother and father died. So did her husband's father.

Now her mother-in-law is in the late stages of Alzheimer's and Parkinson's disease.

There is no job description for caregivers, but the 25 million Americans who provide care for elderly or critically ill family members do anything from shopping for groceries and medicines to bathing, dressing, feeding, cleaning house, and taking care of the family finances. Often they do it all.

As the population of older citizens grows dramatically - by the year 2030 there will be 5.3 million aging baby boomers who need long-term care - many caregivers put their own lives on hold to meet the needs of ill loved ones.

Like Liebich, three-quarters of family caregivers are women. According to the National Alliance of Caregivers and AARP, the average caregiver is a married woman in her mid-40s, a high school graduate who works full time and earns about $35,000 a year. But caregivers can be young, old, male, female, employed or out of work, members of large families and small, of every race, faith and denomination. They're caring for ailing parents, husbands or wives, and even children.

And, according to Carol Levine, an advocate for family caregivers, most "go it alone." Nearly 83 percent have no paid professional help, such as nurses, physical therapists or social workers, and nearly 85 percent have no other paid assistance, such as home health aides.

Shirley Loflin, 66, knows what it means to go it alone. When her 83-year-old mother died in 1993 after a long illness, Loflin was left to care for both her ailing father and her husband, Geddie, who suffered a debilitating stroke.

"Geddie was close to retirement." Loflin said. "We were within touching distance from our dreams of traveling, playing with grandchildren, and finally having time just for one another. Life was full and beautiful until the week before Christmas, when it literally exploded.

"First, Mother died, leaving Daddy alone and bewildered. He couldn't stay by himself, so of course we brought him to live with us. We'd barely settled down to the routine of life together when Geddie, my sweet husband, had a massive stroke, which left him speechless and totally paralyzed on the right side. Within minutes he was reduced to a complete invalid and all our lives changed forever."

Aside from her frantic care-giving duties, Loflin had to deal with daily life and natural disasters in her home in Americus, Ga.

"One week, our old furnace died, the plumbing backed up, the city was in the midst of a huge flood, a small tornado whirled through our neighborhood and ripped off shingles and tree limbs. Debris was everywhere. Geddie had his first seizure and, on top of it all, Daddy was upset because Geddie needed so much of my time."

She got through it all, including the death of her father last October, but the experience shook her. "What scares me most is that you never know what will happen next. Life is from minute to minute. It's living on the edge."

Loflin and Liebich are among the 25 percent of caregivers in the United States who tend to more than one relative at a time. Even more common is the "sandwich generation," the baby boomers who are tending to their parents while still raising their children.

Liebich, 46, falls into that category, too. A one-time manager at a major national insurance company, she embraced the role of full-time wife and mother in 1993. She always assumed that when her son left for college, she would re-enter the work force. The day her mother and father-in-law both ended up in different emergency departments, she realized her career would stay on the shelf a bit longer.

But her management skills were put to good use in her new role. In the car between stops she'd call the pharmacy to check on the latest prescription and check in with her son as he returned home from high school. She started carrying a Palm Pilot to organize her parents' appointments and medications.

"It was a lifesaver," she said. "I have a bad back and I had literally been carrying around many pounds of records." It also was necessary, she adds, because "otherwise the doctors have no idea what each is prescribing."

Despite her savvy, Liebich's family got caught in a bewildering health-care maze, discovering that insurance or Medicare regulations frequently seemed to be at cross-purposes with quality of care.

One day, while her father was being cared for at home, a private aide took her father to the mall so he could go for a "walk" - he could only shuffle a few feet without stopping to catch his breath. A nurse happened by the house while they were gone. The brief walk meant he was not strictly homebound and now ineligible for Medicare home health aides. The twice-weekly, half-hour home visits by the nurse became twice-weekly, two-hour trips to the doctor for Beth and her father.

Caregiving at this level can take a physical toll. While hurrying to get her father situated in his new assisted-living apartment, Liebich broke her back carrying a heavy carton. After a week in bed, she underwent six months of physical therapy and still maintains a stringent strength-training program. Another time, Liebich had an attack of chest pains and it took a night in the hospital and several tests to assure everyone that it was strained muscles and frayed nerves.

The cost to the health-care system of illness and injury among caregivers is significant. A 1997 study by the National Alliance for Caregiving and the AARP found that 15 percent of all caregivers and 31 percent of those providing the highest levels of care experienced significant physical and emotional stress. In another study, over a four-year period, caregivers who reported the highest levels of stress had a 63 percent higher risk of dying than non-caregivers.

The financial picture isn't any brighter. Many Americans simply die poor, with the health care system having absorbed all the money they and their families have.

According to public opinion researchers Lake Snell Perry, caring for an elderly relative ranks as one of the top financial worries for the 21st century, and with good reason. With nursing homes costing more than $3,000 per month, it doesn't take long for most Americans to "spend down" to meet Medicaid criteria for being officially indigent. In a 1999 study funded by the Robert Wood Johnson Foundation of patients with advanced, incurable chronic illness, 29 percent of families reported losing most - or all - of their livelihood. Thirty-one percent lost most or all of the family's life savings. Social Security and pension benefits overall, and out-of-pocket expenses for the care of a single ill relative averaged more than $19,000.

Asked to estimate the amount she and her husband spent in caring for their four parents over the past four years, Liebich quickly ran through the list: There were non-prescription medications, wound dressings and Attends (adult diapers), special food, occasional "Medi-van" transportation to or from the hospital, minor renovations to make the homes safe - handrails in the cellar and halls, elevated toilets, commodes, blood pressure cuffs, and, toward the end, nursing aides from the private duty service. Liebich estimated the total to be in the range of $75,000 to $100,000, maybe more. "Thank God, we had the means to do it," she said. "I don't know what other people do."

After her parents died, Liebich faced sorting through their estate - "the caregiver usually gets that chore, too" - but barely had time to face her grief.

"The time to grieve was virtually instantaneous," she said. "When your mother dies on Saturday, your father-in-law on the very next Monday and your father 2 1/2 months later, your day-to-day workload gets cut by three-quarters, but the grief is always with you."

Proximity had made Liebich the obvious choice to be primary caregiver for their father and mother. But her family pulled together and, she says, in many ways she and her siblings have grown closer during this time, a situation that's not always the case.

It was probably inevitable that Liebich would become an activist for the plight of caregivers. Although she is still caring for her mother-in-law, Liebich has begun writing and speaking out on the issue, intent on educating policy makers, including legislators and the private foundations that fund innovative health and social projects.

Despite the huge stress, many take on caregiving voluntarily and speak easily about its rewards. They talk about the blessings of giving or the growing self-confidence that comes with mastering one difficult task after another. Still others feel the peace of mind that comes from meeting the needs of someone they love. And some learn more than they thought possible.

"Care-giving has taught me many lessons," said Shirley Loflin, "among them, that it is more blessed to give than receive."

Describing the "emotional vocabulary" of caregivers, clinical psychologist and family therapist Barry J. Jacobs said, "They revel in the chance to make a crucial difference in others' lives. Some see it as a means to give back to loved ones who have cared for them so well in the past. Others, taking a more explicitly spiritual view, feel privileged to be the instruments of God's love in conveying comfort and hope. The sense of gratitude these caregivers feel appears to make them more resilient in the face of the long years of demanding work.

How caregivers respond to their challenges depends on how well they care for themselves. Shirley describes it this way: "Yes, I have a mountain of care-giving responsibilities, but my well-being is also important. I began giving myself a little priority."

Caregivers are finding more help out there to do just that, ranging from tips to deal with overwhelming amounts of paperwork to respite care that provides them with "time off," to an array of Web sites containing strategies for coping.

Most important to Loflin is the support provided by people just like her.

“I craved having someone who ‘had been there,’ had experienced what I was going through,” said Loflin. “In the quiet hours of the night, in moments I can catch when my men are asleep or occupied, I’m on the Internet exchanging e-mails with hundreds of other caregivers. We provide huge amounts of support for one another, practical ideas about how to do hard jobs, humor and kindness. These exchanges nourish me and let me nourish others.”

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

Reviewed by athealth on February 1, 2014

What is child abuse and what is child neglect?

Child abuse is defined as any intentional, emotional, physical, or sexual injury to a child.

Child neglect is the most prevalent kind of abuse and can be either physical, emotional, or educational. Child neglect can be intentional or unintentional.

What are some of the behaviors associated with abuse and what injuries do they cause a child?

Physical abuse:

• Bruises, such as those caused by hands, fists, electrical cords, clothes hangers, and belts;
• Internal organ injury which can be difficult to detect but may lead to internal bleeding;
• Bone fractures, especially arms, legs, and skull;
• Burns from such things as cigarettes, lighters, and stove burners;
• Lacerations caused by knives, razor blades, or other sharp objects.

Sexual abuse:

• Inappropriate sexual touching;
• Fondling;
• Rape;
• Prostitution;
• Pornography;
• Sexual abuse of a child includes forcing the child to perform or help to perform any sexual behavior.

Emotional abuse:

• Ridicule;
• Belittling.

Neglect:

• Physical neglect involves a spectrum of behavior. It ranges from refusing to provide basic nutrition or necessary health care for the child to total abandonment of the child.
• Emotional neglect has a wide spectrum of behavior starting with the absence of adequate adult affection toward the child. It includes exposing the child to physical violence within the family.
• Educational neglect occurs when the child's caretakers fail to provide the child with an adequate educational experience.

What are some of the statistics associated with child abuse and neglect?

Neglect is the most prevalent form of abuse. Physical abuse is the second most prevalent form followed by sexual abuse.

About 5 percent of children in the United States are thought to be victims of some form of reported abuse.

According to child abuse surveys, more than 3,000,000 children are reported to child protective services in the United States each year. That means that there are more than 8,000 people every day who are reported to authorities for allegedly abusing a child.

Between 1000 and 1500 children die of abuse and/or neglect in the United States every year.

What leads to child abuse or neglect?

Ignorance can often cause parents or caregivers to neglect a child. For instance, parents who don't understand the special needs of their children or who themselves have not grown up in nurturing environments are more likely to neglect a child by failing to give the child adequate nurturing or important emotional support.

Severe stress can lead an adult to abuse a child. Young, single parents without sufficient emotional support for themselves are more vulnerable to neglect and abuse their children.

Sexual abuse of a child often starts with inappropriate touching or fondling. If the abuse is not stopped, the perpetrator may proceed to full sexual intercourse with the child.

Do men or women abuse or neglect children?

Both men and women can be neglectful or abusive toward children.

At what age are children abused?

Physical, emotional, or sexual abuse can begin in infancy and may continue through adolescence.

How is child abuse discovered or diagnosed?

Abuse can be difficult to detect and diagnose. Abuse of a child is usually reported by someone other than the child's parents. Relatives, neighbors, child care workers, school authorities, or health care providers may become suspicious that a child is being abused and call the authorities. Anyone can report suspected child abuse: teachers, counselors and medical personnel are obligated to report suspected abuse to child protective services. Because abusive adults often threaten their victims, the victim may fear telling anyone, and, therefore, the abuse may continue over a long period of time. Many adults have never talked about the abuse they received as a child. However, today, children are often taught by their parents, other caregivers, and teachers to report any inappropriate adult behavior.

How is child abuse treated?

The most important aspect in treating the child who is physically or sexually abused is to make sure that the child is safe. To insure safety, the child may have to be removed from his/her abusive family. In order to help the child heal from his/her trauma, the child should receive psychotherapy. Therapy helps abused children rebuild their self-esteem, reduce their fears, and regain a trusting relationship with an adult. Parents are almost always strongly encouraged to be involved in the child's therapy.

What happens to children who have been abused?

With proper psychological treatment, children can heal from abuse. However, many children never receive adequate treatment, and these children can carry the scars of abuse into their adult lives. Many adults who were abused as children have never dealt with this trauma in their own lives and, therefore, may themselves become abusive toward their children. Thus, the cycle can repeat itself.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Page last modified or reviewed by athealth on February 1, 2014