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Child sexual abuse includes a wide range of sexual behaviors that take place between a child and an older person. These sexual behaviors are intended to erotically arouse the older person, generally without consideration for the reactions or choices of the child and without consideration for the effects of the behavior upon the child. Behaviors that are sexually abusive often involve bodily contact, such as in the case of sexual kissing, touching, fondling of genitals, and oral, anal, or vaginal intercourse. However, behaviors may be sexually abusive even if they don't involve contact, such as in the case of genital exposure ("flashing"), verbal pressure for sex, and sexual exploitation for purposes of prostitution or pornography.

Who are the perpetrators of child sexual abuse?

• Legal definitions of what constitutes child sexual abuse usually require that the perpetrator be older than the victim. For example, in some states perpetrators must be at least five years older than their victims for the behavior to be considered child sexual abuse.
• Most often, sexual abusers know the child they abuse but are not relatives. In fact, about 60% of perpetrators are nonrelative acquaintances, such as a friend of the family, babysitter, or neighbor.
• About 30% of those who sexually abuse children are relatives of the child, such as fathers, uncles, or cousins.
• Strangers are perpetrators in about 10% of child sexual abuse cases.
• Men are found to be perpetrators in most cases, regardless of whether the victim is a boy or a girl. However, women are found to be perpetrators in about 14% of cases reported against boys and about 6% of cases reported against girls.
• Child pornographers and other perpetrators who are strangers now also make contact with children using the Internet.

How does one know if a child has been sexually abused?

Researchers estimate that, in our country, about 10% of boys and 25% of girls are sexually abused.

Unfortunately, there are often no obvious signs that a child has been sexually abused. Because sexual abuse often occurs in private, and because it often does not result in physical evidence, child sexual abuse can be difficult to detect.

There is not a "child sexual abuse syndrome," or any symptom that a majority of sexually abused children exhibit.

What are some symptoms sexually abused children exhibit?

• Some children may show symptoms of PTSD, including agitated behavior, frightening dreams, and repetitive play in which aspects of the abuse are expressed.
• Because of their sexual abuse, children may show sexual behavior or seductiveness that is inappropriate for their age.
• As a result of abuse, children, especially boys, tend to "act out" with behavior problems, such as cruelty to others and running away.
• Other children "act in" by becoming depressed or by withdrawing from friends or family.
• Sometimes children may try to injure themselves or attempt suicide.

What can parents and caretakers do to help keep children safe?

• Talk to your children about the difference between good touch and bad touch. Tell the child that if someone tries to touch his or her body and do things that make the child feel uncomfortable, he or she should say NO to the person and tell you about it right away.
• Let children know that they have the right to forbid others to touch their bodies in a bad way. Let them know that respect does not always mean doing what those in authority tell them to do. Do not tell them to do EVERYTHING the babysitter or group leader tells them to do.
• Alert your children that perpetrators may use the Internet, and monitor your children's access to online websites.
• Most importantly, provide a safe, caring environment so children feel able to talk freely about sexual abuse.

What should parents and caretakers do if they suspect abuse?

• If a child says she or he has been abused, try to remain calm.
• Reassure the child that what has happened is not his or her fault.
• Seek a medical examination and psychological consultation immediately.
• Know that children can recover from sexual abuse, particularly if they have the support of a caring, available parent.
• Get help yourself. It is often very painful to acknowledge that your child has been sexually exploited. Parents can harm children further if they inappropriately minimize the abuse or if they harbor irrational fears related to the abuse. Therapy can help caretakers deal with their own feelings about the abuse so that they are able to provide support to their children.

What are the possible long-term effects of child sexual abuse?

If child sexual abuse is not effectively treated, long-term symptoms may persist into adulthood.

These may include:

• PTSD and/or anxiety
• Depression and thoughts of suicide
• Sexual anxiety and disorders
• Poor body image and low self-esteem
• The use of unhealthy behaviors, such as alcohol abuse, drug abuse, self-mutilation, or bingeing and purging, to help mask painful emotions related to the abuse

If you were abused as a child and suffer from any of these symptoms, it may help you to get help from a mental-health professional who has expertise in working with people who have been sexually abused.

Selected References

Ackerman, P. T., Newton, J. E.O., McPherson, W. B., Jones, J. G., & Dykman, R. A. (1998). Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse & Neglect, 22, 759-774.

Boney-McCoy, S. & Finkelhor, D. (1996). Is youth victimization related to trauma symptoms and depression after controlling for prior symptoms and family relationships? A longitudinal, prospective study. Journal of Consulting and Clinical Psychology, 64, 1406-1416.

Collings, S. J. (1995). The long-term effects of contact and noncontact forms of child sexual abuse in a sample of university men. Child Abuse and Neglect, 19, 1-6.

Jumper, S. (1995). A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment. Child Abuse and Neglect, 19, 715-728.

Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180.

Neumann, D. A., Houskamp, B. M., Pollock, V. E., & Briere, J. (1996). The long-term sequelae of childhood sexual abuse in women: A meta-analytic review. Child Maltreatment, 1, 6-16.

Source: National Center for PTSD
By Julia Whealin, PhD
Updated May 2003

Reviewed by athealth on February 1, 2014

What Is Child Traumatic Stress?

What is child traumatic stress, how does it develop, and what are the symptoms? To answer these questions, we first have to understand what trauma is.

From a psychological perspective, trauma occurs when a child experiences an intense event that threatens or causes harm to his or her emotional and physical well-being.

Trauma can be the result of exposure to a natural disaster such as a hurricane or flood or to events such as war and terrorism. Witnessing or being the victim of violence, serious injury, or physical or sexual abuse can be traumatic. Accidents or medical procedures can result in trauma, too. Sadly, about one of every four children will experience a traumatic event before the age of 16.

When children have a traumatic experience, they react in both physiological and psychological ways. Their heart rate may increase, and they may begin to sweat, to feel agitated and hyperalert, to feel "butterflies" in their stomach, and to become emotionally upset. These reactions are distressing, but in fact they're normal - they're our bodies' way of protecting us and preparing us to confront danger. However, some children who have experienced a traumatic event will have longer lasting reactions that can interfere with their physical and emotional health.

Children who suffer from child traumatic stress are those children who have been exposed to one or more traumas over the course of their lives and develop reactions that persist and affect their daily lives after the traumatic events have ended. Traumatic reactions can include a variety of responses, including intense and ongoing emotional upset, depressive symptoms, anxiety, behavioral changes, difficulties with attention, academic difficulties, nightmares, physical symptoms such as difficulty sleeping and eating, and aches and pains, among others. Children who suffer from traumatic stress often have these types of symptoms when reminded in some way of the traumatic event.

Although many of us may experience these reactions from time to time, when a child is experiencing child traumatic stress, they interfere with the child's daily life and ability to function and interact with others. Some of these children may develop ongoing symptoms that are diagnosed as post-traumatic stress disorder (PTSD). When we talk about child traumatic stress, we're talking about the stress of any child who's had a traumatic experience and is having difficulties moving forward with his or her life. When we talk about PTSD, we're talking about a disorder defined by the American Psychiatric Association as having specific symptoms: the child continues to re-experience the event through nightmares, flashbacks, or other symptoms for more than a month after the original experience; the child has what we call avoidance or numbing symptoms - he or she won't think about the event, has memory lapses, or maybe feels numb in connection with the events - and the child has feelings of arousal, such as increased irritability, difficulty sleeping, or others. Every child diagnosed with PTSD is experiencing child traumatic stress, but not every child experiencing child traumatic stress has all the symptoms for a PTSD diagnosis.

And not every child who experiences a traumatic event will develop symptoms of child traumatic stress. Whether or not your child does depends on a range of factors. These include his or her history of previous trauma exposure, because children who have experienced prior traumas are more likely to develop symptoms after a recent event. They also include an individual child's mental and emotional strengths and weaknesses and what kind of support he or she has at home and elsewhere. In some instances, when two children encounter the same situation, one will develop ongoing difficulties and the other will not. Children are unique individuals, and it's unwise to make sweeping assumptions about whether they will or will not experience ongoing troubles following a traumatic event.

For children who do experience traumatic stress, there are a wide variety of potential consequences. In addition to causing the symptoms listed earlier, the experience can have a direct impact on the development of children's brains and bodies. Traumatic stress can interfere with children's ability to concentrate, learn, and perform in school. It can change how children view the world and their futures, and can lead to future employment problems. It can also take a tremendous toll on the entire family.

The way that traumatic stress appears will vary from child to child and will depend on the child's age and developmental level. The good news is that over the past decade the mental health community has developed treatments that can help children suffering from traumatic stress. It's important to seek help from someone who has experience working with children and knows how to access resources in your community.

Although not every child will experience traumatic stress, it's unlikely that any of us are immune from exposure to trauma. To learn more about child traumatic stress, please visit the National Child Traumatic Stress Network website at www.NCTSNet.org.

This article first appeared in the fall 2003 issue of Claiming Children, the newsletter of the Federation of Families for Children's Mental Health, www.ffcmh.org, which was co-produced by the Federation and the NCTSN.

Copyright © National Child Traumatic Stress Network
Used with permission

Reviewed by athealth on February 8, 2014.

Jerome arrived home later and later after baseball practice. When his mother asked why, he became very defensive, stormed out of the room and didn’t come out until it was time for school the next morning. As the weeks progressed, Jerome’s parents noticed that their 15-year-old was becoming increasingly moody and irritable. When he did come out of his room long enough for a conversation, he would have very little to say about anything – including his friends, school and sports.

A few days later, Jerome’s father received a call from the baseball coach who was concerned that Jerome had missed a number of practices. When asked, Jerome said he was no longer interested in baseball, though he recently celebrated winning the MVP title for the second year in a row. Time passed and the situation did not seem to get any better. Eventually, Jerome’s parents learned that his grades were slipping dramatically, and the once outspoken Jerome now seemed despondent and unmotivated in class. After a couple of weeks, what looked at first like a “normal teenage phase” to Jerome’s parents seemed to be much more serious. What his parents didn’t realize was that their son was suffering from depression.

“Depression is a real, common and treatable illness that affects millions of Americans,” says Michael Faenza, president and CEO of the National Mental Health Association (NMHA). “As parents, we have to recognize that depression and other mental illnesses are just as real in children and teens as they are in adults.” As many as one in every 33 children and approximately one in eight adolescents may have depression according to the Center for Mental Health Services. Although many people recognize the warning signs of depression in adults — sadness, withdrawal and lack of interest — few parents are aware that the signs of depression may look differently in youth. Besides feeling sad and hopeless, children with depression may also complain of frequent headaches or stomachaches, become irritable or act out.

“Sometimes we only see the behavior problem, like when a child comes home from school in a bad mood and slams the door. Parents are most likely to react to the slamming door — the manifestation of the problem — rather than the underlying issue,” says Bev Cobain, R.N.C., a psychiatric nurse and author of the book When Nothing Matters Anymore: A Survival Guide for Depressed Teens.

Depression is more than just “feeling blue” or having a bad day. Depression is a serious and common medical illness that affects a person’s mind and body. This disease interferes with one’s ability to function and feel pleasure and is accompanied by feelings of sadness, physical discomfort and withdrawal from people and activities. Children and adolescents who have depression can not just “snap out of it,” but may require treatment from a primary care physician or qualified mental health professional. “Ultimately, the consequences of undiagnosed and untreated depression can be extreme,” says Lindy Garnette, the mother of a teenager with depression. “Left untreated, childhood depression can lead to school failure, substance abuse and even suicide.” In fact, suicide is the third leading cause of death for 15- to 24-year-olds and the sixth leading cause of death for 5 to 14-year-olds.

Bev Cobain personally experienced the devastating effect of suicide when her cousin, Kurt Cobain (lead singer for the rock band Nirvana), took his life on April 8, 1994. Cobain remembers the media frenzy surrounding Kurt’s suicide as reporters focused on his drinking, drug use and pain expressed through his music. “Those were just the symptoms of his problems; the real issue was depression,” she explains. High-profile entertainers are not the only people who feel the pain of depression or attempt suicide. It is common for parents to think that suicide is something that affects other families not their own. Suicidal thoughts do not discriminate and do not only affect “problem children.” Thousands of kids, from diverse backgrounds, consider taking their own lives — not to get attention, but to stop the pain, anguish and confusion associated with undiagnosed and untreated mental disorders. When depression goes undiag-nosed and untreated, living a “normal” life seems impossible.

Mental disorders are very treatable once diagnosed by a primary care practitioner or mental health professional. In fact, most people with depression can be successfully treated. As with many illnesses, the key to getting better is diagnosing the problem and having access to appropriate treatment. The sooner the treatment begins the more effective it can be. Treatment options include psychotherapy (talk therapy), psychiatric medication and support services such as peer support groups and social skills training.

“When a child has a fever, parents take the necessary steps to get medical care,” says Faenza. “The same priority needs to apply to treating mental illnesses. Kids want to know they can talk about their problems and that we, as parents, will help them do something about it.”

The Childhood Depression Awareness Program is sponsored by the
National Mental Health Association.

Reviewed by athealth on February 1, 2014

The death of a loved one is a part of the life cycle that brings grief to children as well as to adults. According to the 2000 U.S. Census, 4% of single parents had been widowed; 13.9% of these households included children under the age of 12 (U.S. Census Bureau, 2001). In addition to the death of a parent, many children may also experience the death of a grandparent, sibling, or friend. Parents and teachers can play an important role in helping children deal with loss. This Digest discusses psychological tasks that appear to be essential to children's adjustment, how children understand death and react to the death of a loved one, and how parents and teachers can help children cope with loss.

Children's "Tasks" During Mourning

The Harvard Child Bereavement Study (HCBS), co-directed by J. W. Worden, interviewed and tested 125 children between the ages of 6 and 17 and their families. Standardized instruments, such as the Smilansky Death Questionnaire and the Child Behavior Checklist, as well as interviews, were used in this study. Of these children, 74% had lost a father, and 26% had lost a mother. A similar group of 70 children who had not suffered such bereavement were similarly studied. Worden distinguished among four tasks of mourning for these children: (1) accepting the reality of loss, (2) experiencing the pain or emotional aspects of loss, (3) adjusting to an environment in which the deceased is missing, and (4) relocating the person within one's life and finding ways to memorialize the person (Worden, 1996, pp. 13-15).

Christian (1997), a professor of early childhood education who worked with families with AIDS, observes that, unlike adults, some children may not realize that they can survive without the deceased parent. Baker and Sedney (1996), based on clinical experience and interviews, list early tasks of bereavement for children including self-protection or the need for assurance that they will be safe and cared for. Understanding the death, another task, requires the provision of information to these children on how or why the death occurred. Some experts believe that vague abstractions may leave a child believing that deceased parents could return if they wanted to do so (Corr & Corr, 1996, pp. 120-121). As they mature, experts agree, children need to be able to ask questions about the death repeatedly and to work through their developing understanding of such a major event (Christian, 1997).

How Do Children Understand Death?

Experts suggest that understanding death involves comprehending the concepts of irreversibility, finality, inevitability, and causality (Corr & Corr, 1996). A study of 50 children between the ages of 7 and 12 years explored the understanding of these concepts as affected by variables such as age, experience, and cognitive development (Cuddy-Casey et al., 1997). Based on experience gained from being counselors at the New England Center for Loss and Transition, Emswiler and Emswiler (2000) concluded that prior to age 3, babies may sense an absence among those in their immediate world and miss a familiar person who is gone, but they are unlikely to understand the difference between a temporary absence and death. A preschool child may talk about death but may still expect the person to come back. The National Center for Victims of Crime (NCVC) has pulled together the work of several professionals who work with grief in children. This group theorizes that before age 5, most children do not realize that all people, including themselves, will die. By ages 9 or 10, however, most children have developed an understanding of death as final, irreversible, and inescapable (Worden, 1996, pp. 10-11; NCVC, 2003).

How Do Children React to the Death of a Loved One?

In the HCBS study of children ages 6 to 17 who had lost a parent, children reacted with sadness and tears to the news. In most cases, the crying subsided or lessened over time, although 13% of children still cried daily or weekly even after a year had passed (Worden, 1996). Tears often were triggered by the sight of others crying. Bereaved children also became anxious over the safety of other loved ones or themselves. Many children in this study expressed guilt about remembered misbehavior or missed opportunities to express affection (Worden, 1996).

Parents and teachers may observe outbursts of anger and acting-out behavior among children who have lost a loved one. Somaticization (physical complaints without a disease or physical basis to account for them) increased during the first year after the death of a loved one in 13% of the children studied (Worden, 1996). The number of children experiencing serious illness during the first year increased but fell to match the percentage of nonbereaved children during the second year. A similar pattern was observed in the number of accidents experienced by bereaved children (Worden, 1996).

How Can Parents Help?

Shaw, a specialist in bereavement, trauma, and loss, suggests that parents explain death to children in simple, age-appropriate terms. Shaw (1999) points out that vague euphemisms may be confusing and frightening. She suggests that parents avoid trying to suppress the child's tears or expressions of grief, help the child put feelings into words, and provide honest answers to questions. Children can be given the choice to attend the funeral or other memorial services. If children choose to attend, parents can prepare them beforehand for what they may see and hear, including the grief others may show. Parents can also help children find ways to honor and remember the deceased. Parents may need to reassure children that it is all right for them to resume normal daily activities as well as to play and laugh again (Shaw, 1999).

How Can Teachers Help?

Hogan (2002) suggests that teachers can ease a bereaved child's return to school by offering immediate sympathy to the child, attending the funeral, and talking to the class about the death before the child's return. The teacher can be sensitive to the possibility that activities related to family may make the child uncomfortable. Holidays often bring renewed sadness, and teachers can help children cope with these times of renewed sorrow. The teacher may also mention that others have lost a loved one, so that the child feels less alone and different. Children who have lost a family member can be reassured that in time they will be happy again and that it is appropriate for them to play and have fun.

What Are the Signs That a Grieving Child Needs Extra Help?

The American Academy of Child and Adolescent Psychiatry (1998) cautions parents and teachers that, although most children grieve less over time, counseling might be considered if children exhibit several of these behaviors over an extended period:

• Depression so severe that a child shows little interest in daily activities
• Inability to sleep, eat normally, or be alone
• Regression in behavior to that of a less-mature child
• Imitation of the deceased person
• Repeatedly wishing to join the deceased
• Loss of interest in friends or play
• Refusal to attend school or a persistent and marked drop in school achievement

Conclusion

The death of a parent or loved one during childhood can have profound and lasting effects (Harris, 1995). Further research on the long-term effects of various interventions is needed. The literature suggests that although adults cannot shield children from the sorrow caused by the death of a loved one, they can guide and comfort them through the process of mourning.

Children's Books on Death and Grief

Those who work with grieving children often use literature such as that recommended by Corr (2000) and others (Children's Books on Death and Dying, 1997). These recommended titles include the following books:

Adler, C. S. (1993). Daddy's Climbing Tree. New York: Clarion Books. A father is killed in a hit-and-run accident. Anderson, Leone. (1979). It's O.K. to Cry. Illus. by Richard Wahl. Elgin, IL: Child's World. Two brothers grieve the death of an uncle.

Bartoli, Jennifer. (1975). Nonna. Illus. by Joan Drescher. New York: Harvey House. A family deals with a grandmother's death.

Jones, Penelope. (1981). Holding Together. New York: Bradbury Press. Sisters help each other through the illness and death of their mother.

Stiles, Norman. (1984). I'll Miss You, Mr. Hooper. Illus. by Joe Mathieu. New York: Random House. Big Bird mourns the death of Mr. Hooper. Contains notes for parents.

Viorst, Judith. (1971). The Tenth Good Thing about Barney. Illus. by Erik Blegvad. New York: Antheneum. A child learns about death through the loss of a pet.

Wolfelt, Alan. (2000). Healing Your Grieving Heart: 100 Practical Ideas for Kids. Ft. Collins, CO: Companion Press. Children 6-12 who have had a loved one die find ideas to help with the grief.

Source: ERIC Digest
ERIC Identifier: ED475393
Publication Date: 2003-06-00
Author: Nancy McEntire Page last modified or reviewed on January 6, 2011

Reviewed by athealth on February 1, 2014

How many children of alcoholics are there?

More than 6 million children live with at least one parent who abuses or is dependent on alcohol or an illicit drug.¹

How does alcoholism affect the family?

Alcoholism affects the entire family. The level of dysfunction or resiliency of the non-alcoholic spouse is a key factor in the effects of problems impacting children. Children raised in alcoholic families have different life experiences than children raised in non-alcoholic families. Children raised in other types of dysfunctional families may have similar developmental losses and stressors as do children raised in alcoholic families.

Families with alcoholism have higher levels of conflict than other families. Lack of adequate parenting and poor home management and family communication skills often leave children without effective training and role modeling.^3,6,7

Families with alcoholism often lack structure and discipline for their children; as a result, the children often are expected to take on responsibilities normally assigned to older youth or adults.^3,6

Why should we be concerned about children of alcoholics?

Alcoholism tends to run in families. Children of alcoholics (COAs) are four times more likely than non-COAs to develop alcoholism or drug problems.²

COAs are at higher risk than others for depression, anxiety disorders, problems with cognitive and verbal skills, and parental abuse or neglect. They are significantly more likely than other children to be abused or neglected by their parents or guardians and are more likely to enter foster care.^2,3,4,5

If not prevented, the difficulties faced by COAs can place increased burdens on state and local Governments. These include increased costs for health care, mental health services, child welfare, education, police and juvenile justice, and lost economic opportunity.

How can we help prevent children of alcoholics from repeating their families' alcohol-related problems?

Although they are at increased risk, many COAs do not develop alcohol or drug use disorders or other serious problems in their lives. Often, they appear to be resilient, bolstered by protective factors and the support of caring adults in their lives.^{3,4,5,6,8,9,11}

COAs can be helped, whether or not the alcohol-abusing family members are receiving help. Prevention programs often help COAs reduce stress; deal with emotional issues; and develop self-esteem, coping skills, and social support.⁸ Children who cope effectively with alcoholism in their families often rely on support from a nonalcoholic parent, grandparent, teacher, or other caring adult. Support groups, faith communities, and trained professionals also are available to help.^8,9

What can others do to help children of alcoholics avoid alcohol abuse and other serious problems?

Simple acts of kindness and compassion can make a difference for COAs. By making yourself available to listen, discuss feelings, share interests, and support their efforts to make friends, you can help COAs cope with their present situations and develop the resilience and skills necessary for their futures.¹¹

Tell them they are not alone, that responsible adults are available to help them, and that millions of others have had similar experiences and have grown up to lead healthy, satisfying lives.¹² Remind them that their families' problems are not their fault and not their responsibility to solve. Their jobs are to be children and help take good care of themselves; learn the facts about alcohol, tobacco, and drugs; recognize their risks; and learn how to avoid repeating their families' alcohol abuse patterns.¹⁰

Encourage them to ask for help. Assure them that getting help is a sign of strength. Offer your own examples and be prepared to help them connect with caring, trustworthy adults and with student assistance programs and other services designed to provide them with further skillbuilding and support.¹⁰

References:

1. Office of Applied Studies. (2002). Results From the 2001 National Survey on Drug Abuse. (DHHS Publication No. SMA 02-3758). Rockville, MD: Substance Abuse and Mental Health Services Administration.

2. Grant, B.F. (2000). Estimates of U.S. children exposed to alcohol abuse and dependence in the family. American Journal of Public Health 90(1): 112-115.

3. National Institute on Alcohol Abuse & Alcoholism. (2000). Alcohol and Health: 10th Special Report to the U.S. Congress. Washington, DC.

4. National Center on Addiction and Substance Abuse at Columbia University. (2004). Criminal Neglect: Substance Abuse, Juvenile Justice and the Children Left Behind. New York.

5. U.S. General Accounting Office. (1998). Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Abusers. Washington, DC.

6. National Institute on Alcohol Abuse & Alcoholism. Alcohol and Health: 9th Special Report to the U.S. Congress. Washington, DC.

7. Johnson, J.L. & Leff, M. (1999). Children of substance abusers: overview of research findings. Pediatrics 103(5) Supplement: 1085-1099.

8. Emshoff, J.G. & Price, A.W. (1999). Prevention and intervention strategies with children of alcoholics. Pediatrics 103(5) Supplement: 1112-1121.

9. Werner, E.E. & Johnson, J.L. (2004). The role of caring adults in the lives of children of alcoholics. Substance Use and Misuse 39(5): 699-720.

10. Nastasi, B.K. & De Zolt, D.M. (1994). School Interventions for Children of Alcoholics. New York: Guild Press.

11. Werner, E.E. & Johnson, J.L. (2000). The role of caring adults in the lives of children of alcoholics. Children of Alcoholics: Selected Readings, Vol. 2.

12. Dies, R.R. & Burghardt, K. (1991). Group interventions for children of alcoholics: prevention and treatment in the schools. Journal of Adolescent Group Therapy 1(3): 219-234.

SAMHSA: Children of Alcoholics: A Guide to Community Action (2004)

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

The birth of a child with a disability or chronic illness, or the discovery that a child has a disability, has a profound effect on a family. Children suddenly must adjust to a brother or sister who, because of their condition, may require a large portion of family time, attention, money, and psychological support. Yet it is an important concern to any family that the nondisabled sibling adjust to the sibling with a disability. It is important because the nondisabled child's reactions to a sibling with a disability can affect the overall adjustment and development of self-esteem in both children.

In any family, each sibling, and each relationship that siblings have, is unique, important, and special. Brothers and sisters influence each other and play important roles in each other's lives. Indeed, sibling relationships make up a child's first social network and are the basis for his or her interactions with people outside the family (Powell & Ogle, 1985). Brothers and sisters are playmates first; as they mature, they take on new roles with each other. They may, over the years, be many things to each other -- teacher, friend, companion, follower, protector, enemy, competitor, confidant, role model. When this relationship is affected by a sibling's disability or chronic illness, the long-term benefits of the relationship may be altered (Crnic & Leconte, 1986). For example, the child with a disability may have limited opportunities to interact with other children outside the family; thus, social interaction between siblings often takes on increasing importance.

Each child's personality and temperment play an important role in their response toward a sibling, including one with a disability. Although both positive and negative feelings exist in all sibling relationships, McHale and Gamble (1987) conclude, "...for school-age children and young adolescents, these relationships tend to be more positive than negative in their feeling tone. Furthermore, children with disabled siblings appear to have more positive and fewer negative behavioral interactions than do those with nondisabled siblings..." (p. 141). These positive aspects include higher levels of empathy and altruism, increased tolerance for differences, increased sense of maturity and responsibility, and pride in the sibling's accomplishments (Powell & Ogle, 1985).

Today, many areas have yet to be explored concerning siblings. Parents and professionals, for instance, need more information about sibling adjustment from the perspective of different family systems (Skrtic, Summers, Brotherson, & Turnbull, 1984). For example, how do different family compositions -- the single parent, adopted children, foster children, and families of different cultures -- affect sibling relationships? Powell and Ogle (1985) summarize the importance of studying siblings when they state: "Siblings have much to share; they have much to teach those who wish to help them. They can guide the actions of parents and professionals so that their needs can best be met." (p. 5).

Nondisabled Sibling Reactions and the Family Environment

Living with a brother or sister, including one with a disability, can be rewarding, confusing, instructive, and stressful. Siblings of a child with a disabling condition express a range of emotions and responses to that sibling, similar in most ways to the range of emotions experienced toward siblings who have no disability (Powell & Ogle, 1985). Children react toward a sibling with a disability with feelings of love, empathy, pride, guilt, anger, and support; the predominance and prevalence of these reactions have great impact on the levels of stress and coping ability of the sibling with a disability. The positive or negative nature of the relationships between siblings and among family members may be influenced by factors such as these:

• the family's resources;
• the family's lifestyle;
• the family's child-rearing practices;
• the kind and severity of the disability;
• the number of children in the family;
• the age differences between children in the family;
• the other stress-producing conditions that exist in the family;
• the kinds of coping mechanisms and interaction patterns that exist within the family; and
• the kind and quality of the support services available in the community.

Each child's reaction to having a sibling with a disability will vary depending on his or her age and developmental level. The responses and feelings of the nondisabled sibling toward the sibling with a disability are not likely to be static, but rather tend to change over time as the sibling adapts to having a brother or sister with a disability and copes with day-to-day realities. Preschool-aged siblings, for example, may feel confused, afraid, anxious, and angry about a brother or sisterisability or illness. All children are different; the intensity of a child's concerns, needs, and experiences will vary from sibling to sibling, as will a child's reaction to and interpretation of events. The younger the child the more difficult it may be for him or her to understand the situation and to interpret events realistically. Nondisabled siblings may resent the time their parents give to the sibling with a handicap and perceive it as rejection. They may wonder what is wrong with them that their parents love their sister or brother with a disability more. During the early years the nondisabled sibling may mimic the physical or behavioral actions of the child with a disability, or the nondisabled sibling may regress in behavioral development. Later on, he or she may be prone to extremes of behavior such as "acting out" or becoming the "perfect" child.

Elementary school-aged children may feel embarrassed or ashamed as they recognize differences between their sibling and someone else's brother or sister. They may worry about "catching" or developing the problem, and they may feel guilt because they themselves do not have a disability. They may also feel protective and supportive of their sibling, and this may trigger conflicts with peers.

Young adults may have future-oriented concerns. They may wonder what will become of their brother or sister with a disability. They may also be concerned about how the people they socialize with, date, and later marry will accept the brother or sister with a disability. Additional issues faced by young adults may include genetic counseling when planning their own families, and coping with anxiety about future responsibilities for the brother or sister with a disability or illness.

Family Stress Factors

The birth of a child with a disability, or the discovery that a child has a disability, can produce stress among family members. Stress can also be caused by a number of ongoing factors, or by special circumstances. Siblings need an explanation for the tensions within the family and the cause of the tensions.

Some families are stressed by the amount of financial resources required to meet the needs of the child who has a disability. Some parents may expect nondisabled siblings to accept the brother or sister with a disability as "normal." This expectation can lead to internalized feelings of anxiety and jealousy which the nondisabled sibling may be reluctant to voice. The parents, in turn, may fail to recognize the child's unhappiness and may deny that a problem exists.

During an interview with the Parent Advocacy Coalition for Educational Rights Center, Inc. (PACER), Beth, a young sibling, offered parents some sage advice:

"I think... I'd want them to understand that sometimes siblings are going to get jealous of the extra help and attention that a brother or sister who's handicapped receives. Parents shouldn't get mad about the jealousy or make the kids without a handicap feel too guilty about it if sometimes they resent the extra attention. Parents have to sit down and talk to the brothers and sisters who are nonhandicapped about what the handicap really means. Kids don't automatically understand it by themselves" (Binkard, 1987, p.5).

Nondisabled siblings may feel obligated to compensate for the child with the disability, to make up for that child's limitations. They may be acting as a surrogate parent, assuming more responsibility than would be usual in the care of a nondisabled sibling. On the other hand, siblings may help the family by providing their parents with assistance and support, which they otherwise might not have, in the care of the child with a disability. The nondisabled child may experience jealousy because he or she may be required to do family chores, whereas, the sibling with a disability is not required to do them -- despite the fact that the sibling with a disability may be unable to do them, or would have great difficulty doing them. The nondisabled sibling may resent having to integrate the sibling with a disability into the neighborhood peer group, and may experience or perceive peer rejection because of having a sibling with a disability. Finally, the nondisabled sibling may feel embarrassment because of a siblinghysical characteristics or inappropriate behavior. Essentially, parents, other adult family members, and professionals should realize that nondisabled siblings need special understanding, attention, support and recognition of their unique contributions to the family system (Powell & Ogle, 1985).

Siblings with disabilities, on the other hand, also experience stress as family members. These common stresses include frustration at not being able to make themselves understood; unhappiness at being left to play alone; irritation over constant reminders about everything; withdrawal because of lack of social skills; low self-esteem; and anger resulting from an inability to do things as easily and quickly as their nondisabled brothers and sisters. Through it all, with understanding and support, there are usually many positive interactions and normal sibling give-and-take situations from which each learns and matures.

When parents have a double standard for disabled and nondisabled children, conflicts can arise. Even though the child with the disability, in fact, may need and receive more parental attention, the amount given may be perceived as unfair by nondisabled siblings. Some parents, on the other hand, may tend to overindulge the normal sibling in an effort to compensate for a brother or sister with a disability. The normal rivalry between all siblings may cause the nondisabled sibling to perceive incorrectly that the parents favor or love best the sibling with a disability. Mary expressed the resentment she feels when her brother is dealt with lightly in comparison to her punishments:

"Nonhandicapped kids can get pushed aside when their brothers or sisters have handicaps. Andrew seems to get help naturally --it's like attention to his needs is "built into the system." I'm the bad one, but he can do no wrong. He makes all the messes, but I get into trouble if I don't empty the dishwasher." (Binkard, 1987, p.10)

The Importance of Information

Unlike their parents, siblings may have no knowledge of life without a brother or sister with a disability (Featherstone, 1980). McKeever (1983) tells us that siblings generally are poorly informed about disabilities. Yet siblings' needs for information may be as great, or greater than those of parents, because of their identification with their brother or sister with a disability. It is important to bear in mind that they have limited life experiences to assist them in putting a disability into perspective (Featherstone, 1980). Parents should respect the nondisabled siblings' need to be recognized as an individual who has concerns and questions as well as his or her right to know about the disability. Nondisabled siblings may require information throughout their lives in a manner and form appropriate to their maturity.

For many siblings, anxiety-producing feelings often are not expressed in day-to-day family interactions and discussions, and are shared even less at school. These internalized feelings complicate sibling relationships, for children need to vent their emotions. Children should be given an explanation for their sibling's problems so that they will not make incorrect assumptions.

Parents and professionals need to be aware that there may be a gap between the nondisabled sibling's knowledge and actions. A nondisabled sibling may be able to rationally explain a brother's or sister's disability to inquiring friends or neighbors, but may still exhibit temper tantrums over the same sibling's actions in the home.

Most importantly, the need for information and understanding does not have to be addressed solely by the parents. A child's disability is a concern which should be shared by parents, helping professionals, and society. For example, some progressive clinics and hospitals have designed programs that include siblings from the beginning. These programs offer Family Support Groups which bring entire families together as a means of sharing information and mutual support.

It is important for educators to be sensitive to nondisabled siblings' feelings and needs. Educators can do much to promote positive sibling interactions as well as acceptance of disabilities in all children. During the school years, especially the early years, teachers can help to promote sibling awareness and interaction by providing opportunities for siblings to learn about disabilities. For example, conducting a "sibling day" or a sibling workshop can be an excellent way of introducing siblings to a variety of disabilities. A "sibling day" can be held on a school day or on a weekend.

On this day, activities can include a presentation by "Kids on the Block,"sability simulation games, sign language instruction, and sharing positive experiences about having a sibling with a disability. Siblings who are not disabled might be interested in seeing and/or participating in some of the unique activities in which their brothers or sisters with disabilities participate while in school. For example, siblings of students with orthopedic impairments might see a physical therapy room and go through activities a student might perform in physical therapy. Siblings of students with hearing impairments might learn a song or poem in sign language.

Information puts fears into perspective. In most instances, simply knowing the facts about a disability or chronic illness takes away the sting of embarrassment, as well as uncertainty and fear. While embarrassment can and does occur in many situations over the years, knowledge can help one cope.

Ask parent groups, social workers, therapists, doctors, teachers, or counselors about the availability of support groups and other sibling resources in your area.

The Impact On a Sibling With a Disability or Chronic Illness

Most of the sibling research has focused on the effects of a child with a disability or chronic illness on nondisabled siblings. Also important is the influence of the nondisabled sibling on the child with a disability or chronic illness. Crnic and Leconte (1986) report that the nondisabled sibling's impact upon the child with a disability may vary across the family's life. While very little work has been done in this area, researchers do stress the reciprocity of sibling relationships.

"I Never Figured You Were Disabled" - A Sister's Experience

"I just don't have a picture of you being disabled," my younger brother muses as we discuss growing up. "There was never a suggestion in our parents' voices about 'your disabled older sister.'"

I am writing as a sister with two invisible disabilities: a moderate-to-severe high frequency loss in both ears, which causes my speech to slur consonants, and the functional use of my left eye to restrain my weaker right eye from producing double vision. These conditions result from my premature birth at six months.

Although my visual and aural disabilities aren't severe, they've affected the way I communicate with my brother and react to him. Since I pick up my aural information from lipreading with one faulty eye, I don't trust the information I receive. This leads to a general mistrust of all my perceptions and a dependence on others for making decisions instead of trusting my sense of inner truth.

My family refuses to think of me as "handicapped." This encourages me to challenge myself academically, but this denial doesn't acknowledge or respect how faulty communication impairs the first impression which influences so many interpersonal and business relationships. Denial colors my brother's one clear memory of my hearing loss. He remembers, "The one thing that bothered me the most was when I had to repeat things. It seemed kind of selective. If I whispered, "There's ice cream in the freezer," you'd hear me, but not if I said, "It's your turn to do the dishes tonight."

I have other memories. My brother has a great sense of humor, which he displays in teasing with a deadpan face. I would often be furious at some "joke" and would yell at him, completely missing the vocal inflections that relay the "humor." And other kids' reactions to my speech and hearing loss have led me, for many years, to interpret all teasing, laughter, and whispers as being directed against me. I come from a traditional family that gave the younger son much more independence than the daughter. A greater protectiveness, beyond gender differences, belied verbal assurances that I was typical. My mother ran my Girl Scout troop to keep the other kids from teasing me. I was in my mid-teens before my parents trusted me to ride a bike, where my younger brother wheeled around at ten.

As I grew into my teens, I avoided the anger and jealousy I felt toward my brother by spending hours in my room reading. As he was three-and-a-half years younger, he constantly asked me to play with him, only to have me turn him away. But as I got used to his teasing, his wonderful sense of humor disarmed me. We hid our emotional intensity in endless arguments about politics and foreign policy.

During our conversation about growing up, my brother also adds, "When you grow up with somebody, you don't see anything different. That's the way they are -- that's my sister." As I come to terms with the physical and psychological meaning of my hearing loss, I read acceptance in those words.

In thanks to my brother for our experiences growing together, I'd like to tell parents, brothers, and sisters about the strengths my disability has given me and my family. Because a partial hearing loss forces me to fill gaps, I have developed an active sense of nonverbal cues from facial expression, mouth movement, and shifts in vocal intensity. My brother's teasing gave me plenty of practice here! I'm just beginning to trust the truth of clues.

I am developing a sense for subtle shifts in people's responses to me that tells me whether I have picked up on the underside of their speech or whether I am way off base. What this means in families is that children with hearing loss are very acute in discerning if the verbal cue does not match the underlying nonverbal feeling or behavior. And it's very easy, if a parent or sibling is uncomfortable with the accuracy of this discernment, to say that the child didn't hear correctly.

The "selective" hearing that my brother mentions is a trait all children have! I have known kids with keen hearing to go "deaf" when dishes are mentioned. Also, it's a function of the extra "sense" that I have had to develop. People usually lower their voices or use a different pitch to say censored, pleasurable, or emotionally-laden phrases. This signals to me that something important is coming, so I increase my concentration or alertness.

My family has allowed me to educate them on the challenges facing a sister with a hearing loss. Some of these challenges are as follows: It takes an enormous amount of energy and concentration for me to listen to conversations, especially in group situations. I am most comfortable one to one, or in groups of two to four people. Unless I can see the person's lips, it's impossible for me to hear conversations in the dark. I still have to tell my family not to dim the lights for those cozy living room discussions. I find it difficult to listen to anyone with a television on or music playing. All these things come up within families.

When I am emotionally upset, I find it much harder to hear. It's necessary to slow down, rephrase sentences, and give me time to process things. This is hard to do in a fight or when someone's crying. Also, I tend to interrupt a lot because it's difficult to distinguish a phrase from a full stop.

For all families: Use your differences and your gifts to imagine the fullest life each family member can live. There is a difference between being "disabled" and "having a disability." If I am "disabled," that defines who I am. If I "have" a disability, I have certain choices as to how this physical and psychological reality limits what I do and how I live. If other people recognize and respect that disability, we can work together to create ways to stretch those limits.

Planning For The Future: Sibling Concerns

Planning for the future raises many important issues for the family of a child with a disability. Powell and Ogle (1985) note that the most challenging of these dilemmas is the care of the adult sibling who has a disability. Even though nondisabled adult siblings have lives (and often families) of their own, they face unusual, additional responsibilities because of their unique relationship with their brother or sister with a disability.

The amount of responsibility that adult nondisabled siblings assume for their adult sibling with a disability varies with individuals and with circumstances. It is dictated by a consideration of family and job responsibilities, personal choice, and available community support.

Perhaps the most challenging issue families face is, on the one hand, encouraging and fostering the independence and self-determination of the person with a disability and, on the other hand, facing the reality that, at some level, assistance may be necessary.

Planning for the Future: An Adult Siblings's Suggestions

When I was about eleven, my older brother and I developed a scheme to dupe my mom. One of us would find an excuse to keep her out of the house as long as possible while the other would "teach" our little sister how to climb the stairs. Karen has severe disabilities and Mom was afraid she would really hurt herself falling down the stairs. My brother and I were typical kids, we didn't think about the risks, just that all kids need to get around by themselves and Karen should learn to climb stairs. I can't recall how many times Karen tried and tried (and fortunately I've just about forgotten how many times she bounced off the bottom step), but I remember vividly the day my brother brought Mom to the stairs and said, "Look what Karen can do!" That was a red letter day for all members of our family.

Families are expected to care for an infant or young child who is very dependent, and to provide experiences that eventually will lead to the independence of that person. Karen tells me that she needs to be independent through her actions. I've seen her work at a task over and over again until she succeeds, despite the bumps she gets along the way. Karen is so proud of her every accomplishment. She wants others to be proud of them, too.

It is essential to avoid seeing the person with a disability as "the dependent." The sibling with a disability should be empowered through early training and attitudes to act as independently as possible, and to make his or her own choices; as with all of us, some choices will be mistakes. It is equally important to avoid making the sibling without disabilities adopt a parental attitude of responsibility toward the sibling with disabilities.

In looking back over my childhood, I am grateful to my mom for encouraging my independence and for being moderate in her expectations that I care for my sister. Yet, family members are often interdependent throughout their lives. The concept of interdependence is important when considering the relationships of siblings when one has a disability.

I want to be involved in making crucial family decisions. If a family member has a disability, it is important to involve that person, as all others, in any decision-making.

In my experience, and from discussions with other siblings of people with disabilities, I have learned that the best way to foster a positive relationship among family members and a strong commitment to each other is to let them choose the levels and intensity of involvement with each other. I have noted that for me, these levels have fluctuated over time and during various circumstances. My relationship with Karen was strengthened when I came to view my involvement with her as a collaboration. Collaboration can be encouraged, but never coerced.

When I was young I used to get pretty good grades, but I went through a very painful period wondering when my grades would change and I would "grow retarded" like my sister. I never talked with anyone about those fears. Initially, I was afraid to talk about this because I dreaded the answer. Later, when I understood what retardation was, I felt guilty that I had such thoughts. As I grew older, one of my most pressing concerns was what would happen to Karen as she became an adult. I was concerned about my family's ability to provide adequate care for her and where she would live and work as an adult.

I know it's easier to say that siblings should be involved in planning for the future care of their brother or sister with disabilities than it is to involve them. I also know that the emotional ramifications of this are sometimes subtle and not always easily recognized. With respect to financial planning, moms and dads don't usually sit down with their kids and say, "OK, folks, I want to let you know the details of our finances now and our financial prospects for the future." This topic is difficult for parents and children alike. But you must attend to this in some way if family members are going to be prepared to take over the care of, or responsibility for, a person with disabilities. I remember all too well the day I finally got the courage to ask my mom about her insurance provisions for my sister. Her answers were anticlimatic compared to the effort and energy I had spent getting the courage to ask the question.

The difficulty with planning for the future is that it forces family members to deal with the inevitability of death. Sitting down and actually discussing these details can be very disturbing to everyone concerned. My mom says she's going to live forever; that she has too many responsibilities to ever abandon them. While we both know this isn't so, no matter how much we wish it were, it's hard to discuss the inevitable. As an adult, I now know how difficult it is to come face to face with one's own mortality.

I strongly recommend that siblings without disabilities, as well as persons with disabilities, be involved in planning for the future as soon as they are old enough to understand the issues. Thus these financial and future planning discussions will most likely begin during early adolescence. The teenage years are a terrible time to have to cope with mortality. However, I can promise you that sitting down and getting these issues out into the open will be much easier in the long run for everyone.

I've had many sleepless nights, starting when I was a teenager, working through these problems by myself, afraid and overwhelmed, before my family started discussing the issues more openly with me.

When people ask me what my needs are as a sibling of a person with severe disabilities, I tell them that I need the commitment from society that every person has a right to a basic quality of life. I believe that my sister has a right to live and work in her community, and a right to lead a life of her own, with some assistance. For me to be powerful in my collaboration with Karen in meeting these goals, I need resources to make this commitment become a reality.

I'd like to have my sister live up the street, in a house with other people with disabilities with whom she can share responsibilities and experiences. If she lived up the street, she could come over for dinner, my future children could go to their aunt's house to visit her, and she could plant and tend her own garden, something she loves to do.

When I moved to my new neighborhood, I did as I always do, called about community living and work options for my sister. I was told that the current waiting list for group homes was ten years long! I asked the social services worker what I would do if tomorrow my sister needed a place to live. The worker told me that in certain emergencies people could be moved to the top of the list, and then they had to wait only three years! When I asked what one would do in the meantime, the social services worker retorted, "I guess you'd have to quit work and stay with her."

Until society can be mobilized to provide a continuum of services throughout life to citizens with disabilities -- services that allow a person to live a quality life with some independence, no matter what the level of disability -- there will continue to be tremendous stresses on family members. Families should not be expected to bear the total burden; they cannot.

Today, due to pressures from parents and professionals, we have laws guaranteeing a free, appropriate, public education to our nation's children and youth with disabilities. But after the child has aged out of public school, he or she again becomes the responsibility of the family. A continuum of accessible and appropriate services should be available to people with disabilities from birth to death. Just as people united for the passage of special education laws and programs for the school-aged child, we must unite to work for the adequate provision of community-based services and housing for adults with disabilities. Society must share more of the responsibility with the family for providing necessary services. I maintain a positive attitude and believe that this will happen, in time. I just want to make sure that it happens in time for Karen and me.

Suggestions for Families

When planning for the future of the sibling with a disability, you should consider such things as mobility, social and communication skills, education, and the individual's own ideas about where to live and work. Even after careful planning and the appointment of a guardian or co-guardians, plans should be made for emergencies. A file should be kept in a safe place, known to all family members. The following ideas should be addressed when making future plans and the information should be included in this accessible file:

1. Develop financial plans for future care. If the family is considering establishing a trust for the family member with the disability, it should consider the incomes of the children in the family, including the sibling with a disability. Make a will only with an attorney experienced in devising wills for those who have an heir with a disability. Inheritances must be treated with caution. It is especially important to investigate the continued eligibility for certain social services if assets from an estate, pension, or life insurance are left to the child with a disability.
2. Know your state's laws regarding guardianship and independence. Do not assume that you as parents will automatically remain your child's guardian when he or she reaches the age of majority in your state. Establish whether the sibling with a disability requires no, partial, or full guardianship. This information should be in writing, and, if possible, make contingency plans in case the first-choice guardian is unable to assume that role. Be aware of the consequences in your state of not having a guardian appointed.
3. Know your state's laws regarding guardianship and independence. Do not assume that you as parents will automatically remain your child's guardian when he or she reaches the age of majority in your state. Establish whether the sibling with a disability requires no, partial, or full guardianship. This information should be in writing, and, if possible, make contingency plans in case the first-choice guardian is unable to assume that role. Be aware of the consequences in your state of not having a guardian appointed.
4. Nondisabled siblings should know where to access the needed educational, vocational, and medical records of the disabled sibling, and be ready to anticipate his or her changing future needs.
5. Families should consider the future health of the sibling with a disability with respect to needed services and care. Parents should document where he or she can receive medical care and the financial resources and arrangements necessary for this care.
6. Families should gain an understanding of the legal and eligibility requirements of programs available to the family member with a disability. Investigate resources through government programs, such as Supplemental Security Income (SSI), Vocational Rehabilitation, Independent Living Centers, employment services, parent and disability groups.
7. Families should discover the types of community resources available. The range of services and resources varies considerably according to place of residence. Keep abreast of any changes in the availability of these services. Consider the sibling's need for long-term care, as well as for employment and companionship.
8. Be aware that, as families grow and develop, the members within it change. Living with and caring for a child with a disability is different from living with and caring for an adult with a disability.  

Family members should continually ask themselves the following questions:

What are the needs of the sibling with a disability?

• How will these needs change?
• What can be expected from local support groups in the community?
• What is and will be my level of involvement?
• Is the involvement financially, emotionally and psychologically realistic for me?
• How will the responsibility be shared with other family members?
• Are my career plans compatible with my responsibilities for my brother or sister with a disability?
• Will my future spouse accept my brother or sister?

The care of a sibling with a disability or chronic illness is, in large part, a family affair and a responsibility that should be shared as evenly as possible. By planning effectively for the future, parents can help ease the responsibility and the feelings of stress that uncertainty about the future can bring.

Suggestions to Parents

Parents set the tone for sibling interactions and attitudes by example and by direct communications. In any family, children should be treated fairly and valued as individuals, praised as well as disciplined, and each child should have special times with parents. Thus, parents should periodically assess the home situation. Although important goals for a child with special needs are to develop feelings of self-worth and self-trust, to become as independent as possible, to develop trust in others, and to develop to the fullest of his or her abilities, these goals are also important to nondisabled siblings.

To every extent possible, parents should require their children with disabilities to do as much as possible for themselves. Families should provide every opportunity for a normal family life by doing things together, such as cleaning the house or yard; or going on family outings to the movies, the playground, museums, or restaurants. Always, the child with the disability should be allowed to participate as much as possible in family chores, and should have specific chores assigned as do the other children.

Caregiving responsibilities for the child with a disability or chronic illness should be shared by all family members. It is especially important that the burden for caregiving does not fall onto the shoulders of an older sibling. If there is an older sister, there is a tendency in some families to give her the primary responsibility, or an excessive amount of it. Today, however, more communities are providing resources to ease the family's caregiving burdens. Examples include recreation activities, respite care, and parent support groups.

Powell and Ogle (1985) present several strategies suggested by nondisabled siblings themselves for parents to consider in their interactions with their nondisabled children.

These siblings suggest that parents should:

• Be open and honest.
• Limit the caregiving responsibilities of siblings.
• Use respite care and other supportive services.
• Accept the disability.
• Schedule special time with the nondisabled sibling.
• Let siblings settle their own differences.
• Welcome other children and friends into the home.
• Praise all siblings.
• Recognize that they are the most important, most powerful teachers of their children.
• Listen to siblings.
• Involve all siblings in family events and decisions.
• Require the disabled child to do as much for himself or herself as possible.
• Recognize each child's unique qualities and family contribution.
• Recognize special stress times for siblings and plan to minimize negative effects.
• Use professionals when indicated to help siblings.
• Teach siblings to interact.
• Provide opportunities for a normal family life and normal family activities.
• Join sibling-related organizations.

Children with special needs, disabilities, or chronic illness may often need more help and require more attention and planning from their parents and others in order to achieve their maximum independence. Brothers and sisters can give parents some of the extra help and support they need; the special relationship of brothers and sisters, disabled and nondisabled, is often lifelong. This special and unique bond among siblings can foster and encourage the positive growth of the entire family.

"Where is Marianne?" by Patty McGill Smith, Acting Assistant Secretary Office of Special Education and Rehabilitative Services U.S. Department of Education

I have a daughter named Marianne. She is 14 years old and so pretty. Marianne may giggle constantly, and then sometimes grow very somber. She is a fantastic young lady of whom I am so proud. She plays soccer and basketball; she can cook and clean; and she has sensitivities far beyond her age. Several trophies line the shelf in her room, and she recently won a scholarship for high school.

Yes, Marianne can do all kinds of things, and she is in and out of love every other week. While so much she does is so normal, there are some other things about Marianne and her life that are unusual.

Marianne was three years old when her sister, Jane, was born. The next two years in Marianne's life are a blur in my memory. Yet, I can recall vividly what happened to Jane during that time. You see, Jane was born with a disability. We did not confirm her disability until she was 14 months old. Those first 14 months were filled with apprehension, concern and crying, and the fussing and fretting of a demanding little baby. The next 12 to 14 months, the months after the diagnosis, were filled with more concerns, confusion, distress, dismay, and heartbreak.

I wonder where Marianne was during those two and a half years. What was she thinking during that time and what was happening to her?

If you don't have a child with a disability in your family, you can't imagine the impact this event has upon the entire family. So much of family life -- the emotion, time, and concern -- is focused on the child with the disability. After that, parents are consumed with coping and survival. There is so much to think about: medical treatment, another opinion, insurance, money, weariness, and wondering why it happened to you. There just is never a convenient time to consider the Mariannes of the world.

It was difficult or impossible at the time to see the situations in which the siblings were being slighted. The slights were not intentional and there was no lack of love. When Marianne and her older sister, Patricia, were four and five years old, respectively, I enrolled them in dance class. This was one of the first realizations I had as a parent that they were not getting as much time, energy, and effort as their little sister with a disability. After that, I can recall making a conscious effort to change things. I remember how important it became that their costumes for the dance recitals were all that they should be. I remember sitting the children down and saying, "Jane takes more of Mommy's time and energy. It isn't that I love her more; it is just that she needs more. You see, she needs more car rides for her doctor visits and evaluations, and more time for her programs. So it ends up that she gets more of my time." Do you suppose that Marianne, her sister, and her brothers who were older were able to accept those kinds of ideas? I don't know.

I do know that at some point in those early years things did change. Gradually, all the children became involved in assisting with Jane's programming. It was great fun to see members of the family join in to help. When Jane began to respond to their teachings, the children taught all the harder. I remember when my oldest son, Mark, taught Jane to "give me five." I remember telling teachers that our household had become a household of speech therapists. "Watch my lips" must have been uttered a hundred times a day; everybody was trying to get Jane to continue to develop her speech patterns. All these things were done in a light and joyful way that made them lots of fun. I, however, look back and wonder if it was too much for them? "How was Marianne being affected?"

I think about other things, too. I remain amazed by the enormous difficulty of motivating normal children to do their best when so much time and effort goes into the development of the child with the disability. What a disappointment when the grades of the siblings come home and they are not all A's. You know they could all be A's, and yet, how do you motivate the normal children to work to their full capacity? I didn't know then, and I don't know today. Then there was the overemphasis on the accomplishments of the child with the disability. Were the accomplishments of the normal siblings similarly heralded? I don't think so. Yet, my Marianne and all the rest seemed to be happy children.

What about the resentment when Jane was learning tasks? It never seemed as though she kept up. Jane, as well as the rest of the children, had assigned tasks around the house and yard. Yet, wasn't it easier to get the older kids to do a job than it was to have Jane do it? I think so. What about the time I gave to teaching the older children skills? Was equal time given? I don't think so. I remember the summer we taught Jane to clean her bedroom. It had been Marianne's job to teach Jane the finer points of room cleaning, but Marianne didn't want to do it. Do the normal siblings become resentful? Does this resentment create other troubles? I think so. Will Jane ever catch up and be able to fully meet the family's requirements of its members? I don't think so.

Is having a child with a disability going to adversely affect the development of the children who have no disabilities? Each family needs to consider this possibility and work to avoid inadvertently hurting the ones we love.

Have I personally ever gotten an answer to this question? Indirectly, yes, for despite all the uncertainties, my children have grown and matured into adults of whom I am proud. However, Gene, my oldest son, gave me what was perhaps the most direct answer I am sure I ever got to an unasked question. When he left home for college, he wrote me a letter. In this "lonesome" letter, in which he expressed his longing for family and friends, he spoke of all his brothers and sisters. Of Jane he said, "... and Jane, well Jane is probably the greatest blessing to us in the world."

Did he mean that he was glad that she was born with a disability? Quite the contrary. He was saying that Jane and her needs had brought us together as a family. It was true; Jane had been a focal point around which we all rallied. We worked as individuals and as a family to help her. Jane had become a total family effort.

Over the years, as a family, and as individuals we have had many successes and some setbacks. Yet, we know none of us has to be alone. We know how to pull together as a family, to love, support, and share -- something we learned how to do a long time ago with Jane.

A Final Word

It is important for parents, siblings, and professionals to utilize the positive resources discussed here in order to cope with a variety of special circumstances, and to adapt them to meet individual needs as they change. Together, family members, as well as professionals, must strive to accent the "abilities" of disabilities, not only for a brother or sister with a disability, but for the entire family.

References

Bibliographic Note:

You can obtain many of the documents listed below through your local public library. Whenever possible, we have included the publisher's address or some other source in case the publication is not available in your area. The organizations listed are only a few of the many that provide various services and information about siblings. Additional support is also available from state and local parent groups, as well as from state and local affiliates of major disability organizations. Please note that these addresses are subject to change without prior notice. If you experience difficulty in locating these documents or organizations, or if you would like additional assistance, please contact NICHCY, by writing to PO Box 1492, Washington, DC 20013, or by calling 1-800-695-0285 (V/TT) or (202) 884-8200 (V/TT).

If you know of a group providing support services for siblings and their families in your area, please send this information to NICHCY for our resource collection. We will appreciate this information and will share it with other families and professionals, who request it.

Binkard, B. (1987). Brothers & sisters talk with PACER. Minneapolis: PACER Center. (Available from PACER Center, Inc., 4826 Chicago Ave., South, Minneapolis, MN 55417.)

Crnic, K. A., & Leconte, J. M. (1986). Understanding sibling needs and influences. In R. R. Fewell & P. F. Vadasy (Eds.), Families of handicapped children: Needs and supports across the life span (pp. 75-98). Austin: Pro-Ed. (This book is no longer in print but may be available through your public library.)

Dougan, T. (1983). Let the good times roll. In T. Dougan, L. Isbell, & P. Vyas (Eds.), We have been there (pp. 119-122). Nashville: Abingdon Press.

Featherstone, H. (1980). A difference in the family: Life with a disabled child. New York: Basic Books, Inc. (Available from Special Needs Project, 3463 State Street, Suite 282, Santa Barbara, CA 93105. Telephone: (805) 683-9633 or 1-800-333-6867.)

McHale, S. M., & Gamble, W. C. (1987). Sibling relationships and adjustment of children with disabled brothers and sisters. In F. Fuchs Schachter & R. K. Stine (Eds.), Practical concerns about siblings: Bridging the research-practice gap (pp. 131-158). New York: Haworth Press. (Available from Haworth Press, Inc., 10 Alice Street, Binghamton, NY 13904-1580. Telephone: 1-800-342-9678.)

McKeever, P. (1983). Siblings of chronically ill children: A literature review with implications for research and practice.American Journal of Orthopsychiatry, 53(2), 209-218.

Meyer, D. J., Vadasy P. F., & Fewell, R. R. (1985). Living with a brother or sister with special needs : A book for sibs. Seattle: University of Washington Press. (Available from University of Washington Press, P.O. Box 50096, Seattle, WA 98145-5095. Telephone: 1-800-441-4115.)

Powell, T. H., & Ogle, P. A. (1985). Brothers & sisters: A special part of exceptional families. Baltimore: Paul H. Brookes Publishing. (A second edition of this book is available from Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21204. Telephone: 1-800-638-3775.)

Skrtic, T. M., Summers, J. A., Brotherson, M. J., & Turnbull, A. P. (1984). Severely handicapped children and their brothers and sisters. In J. Blancher (Ed.), Severely handicapped young children and their families: Research in review. New York: Academic Press. (Available from Academic Press, 6277 Sea Harbor Drive, Orlando, FL 32887. Telephone: 1-800-545- 2522.)

Bibliography

General Interest:

Azarnoff, P. (1983). Health, illness, and disability: A guide to books for children and young adults. New York: R.R. Bowker. (Available from R.R. Bowker, c/o Reed Reference Publishing, 121 Chanlon Road, New Providence, NJ 07974. Telephone: 1-800- 521-8110.)

Corlin, M., Laughlin, J., & Saniga, R. (1991). Understanding abilities, disabilities, and capabilities: A guide to children's literature. Englewood, CO: Libraries Unlimited. (Available from Libraries Unlimited, P.O. Box 6633, Englewood, CO 80155-6633. Telephone: 1-800-237-6124.)

Emmett, M. (1989). I'm the big sister now. Niles, IL: Albert Whitman. (About a sibling of a child with cerebral palsy, suitable for pre-K through early elementary. Available from Albert Whitman, 6340 Oakton Street, Morton Grove, IL 60053. Telephone: 1-800-255- 7675.)

Epilepsy Foundation of America. (1992). Brothers and sisters: A guide for families of children with epilepsy. Landover, MD: Author. (Available from the Epilepsy Foundation of America, 4351 Garden City Drive, Landover, MD 20785. Telephone: 1-800-332-1000.)

Friedman, J.B., Mullins, J.B., & Sukiennik, A.W. (1985). Accept me as I am: Best books of juvenile nonfiction on impairment and disabilities. New York: R.R. Bowker. (Available from R.R. Bowker, at address listed above.)

Hecker, H. (1994). Children's disability bookstore catalog. Vancouver, WA: Twin Peaks. (Available from Twin Peaks Press, P.O. Box 129, Vancouver, WA 98666-0129. Telephone: (206) 694-2462.)

Lobato, D.J. (1990). Brothers, sisters, and special needs: Information and activities for helping young siblings of children with chronic illness and developmental disabilities. Baltimore, MD: Paul H. Brookes Publishing. (Available from Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21204. Telephone: 1-800-638-3775.)

McCaffrey, F.D., & Fish, T. (1989). Profiles of the other child: A sibling guide for parents. Columbus, OH: Nisonger Center. (Available from the Nisonger Center, Publications Office, McCampbell Hall, Room 434, 1581 Dodd Drive, Columbus, OH 43210. Telephone: (614) 292-8365.)

Meyer, D. J., Vadasy, P. F., & Fewell, R. R. (1985). Living with a brother or sister with special needs: A book for sibs. Seattle: University of Washington Press. (Available from University of Washington Press, P.O. Box 50096, Seattle, WA 98145-5096. Telephone: 1-800-441-4115.)

Muldoon, K.M. (1989). Princess pooh. Niles, IL: Albert Whitman. (About a young girl and her sister who uses a wheelchair, suitable for pre-K through grade 3. See Albert Whitman address above.)

Powell, T., & Gallagher, P.A. (1993). Brothers and sisters: A special part of exceptional families (2nd ed.). Baltimore, MD: Paul H. Brookes. (See address above.)

Shulman, S. (1988). The family of the severely handicapped child: The sibling perspective. Journal of Family Therapy, 10(2), 125-134.

Thompson, M. (1992). My brother Matthew. Rockville, MD: Woodbine House. (Intended for siblings, grades K-5. Available from Woodbine House, 6510 Bells Mill Road, Bethesda, MD 20817. Telephone: 1-800-843-7323; (301) 897-3570.)

Magazines and Newsletters:

The Bond. A quarterly newsletter intended for siblings and adult children of individuals with mental illness. (For subscriptions, contact Siblings and Adult Children Network, National Alliance for the Mentally Ill, 200 N. Glebe Road, Suite 1015, Arlington, VA 222031. Telephone: (703) 524-7600.)

The Exceptional Parent. A magazine for parents of children with disabilities published twelve times a year. (Write: Psy-Ed Corporation, P.O. Box 3000, Denville, NJ 07834. Telephone: 1-800-562-1973.)

NASP Newsletter. A newsletter published for service providers. (Available from National Association of Sibling Programs, Sibling Support Project, Children's Hospital and Medical Center, P.O. Box 5371, CL-09, Seattle, WA 98105-0371. Telephone: (206) 368-4911.)

Sibling Information Network Newsletter. A newsletter for siblings, published quarterly. (Write: Sibling Information Network, A.J. Pappanikou Center, 62 Washington Street, Middletown, CT 06475. Telephone: (203) 344-7500.)

Organizations:

The Sibling Information Network- A.J. Pappanikou Center, 62 Washington Street, Middletown, CT 06475. Telephone: (203) 344-7500. Siblings for Significant Change- 105 East 22nd St., New York, NY 10010. Telephone (212) 420-0430.

Parent Advocacy Coalition for Educational Rights (PACER) Center- PACER, is a Center of "parents helping parents". PACER's programs help parents and children becomed informed and participating members in the life of a child with disabilities. In addition to a resource listing of publications and a newsletter, PACER offers many workshops. Write: PACER Center, Inc., 4826 Chicago Ave. South, Minneapolis, MN 55417. Telephone: (612) 827-2966.

Siblings of Disabled Children- A program of Parents Helping Parents, offers two groups, one for ages 8-12, and one for ages 13-17. The objective is to give siblings special attention relating to their needs around being a member of an exceptional family. Their newsletter is called, Sibling Squabble. Write: Parents Helping Parents, Inc., 3041 Olcott, Santa Clara, CA 95054-3222. Telephone (408) 288-5010.

Sibling Support Project, Children's Hospital and Medical Center, P.O. Box 5371, CL-09, Seattle, WA 98105-0371.

---

National Information Center for Children and Youth with Disabilities
Updated 1994

Reviewed by athealth.com on February 1, 2014

What is chlamydia?

Chlamydia is a common sexually transmitted disease (STD) caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man.

How common is chlamydia?

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. In 2009, 1,244,180 chlamydial infections were reported to CDC from 50 states and the District of Columbia. Under-reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms. An estimated 2.8 million infections occur annually in the U.S. Women are frequently re-infected if their sex partners are not treated.

How do people get chlamydia?

Chlamydia can be transmitted during vaginal, anal, or oral sex. Chlamydia can also be passed from an infected mother to her baby during vaginal childbirth.

Any sexually active person can be infected with chlamydia. The greater the number of sex partners, the greater the risk of infection. Because the cervix (opening to the uterus) of teenage girls and young women is not fully matured and is probably more susceptible to infection, they are at particularly high risk for infection if sexually active. Since chlamydia can be transmitted by oral or anal sex, men who have sex with men are also at risk for chlamydial infection.

What are the symptoms of chlamydia?

Chlamydia is known as a "silent" disease because the majority of infected people have no symptoms. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra (urine canal). Women who have symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from the cervix to the fallopian tubes (tubes that carry fertilized eggs from the ovaries to the uterus), some women still have no signs or symptoms; others have lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.

Men with signs or symptoms might have a discharge from their penis or a burning sensation when urinating. Men might also have burning and itching around the opening of the penis. Pain and swelling in the testicles are uncommon.

Men or women who have receptive anal intercourse may acquire chlamydial infection in the rectum, which can cause rectal pain, discharge, or bleeding. Chlamydia can also be found in the throats of women and men having oral sex with an infected partner.

What complications can result from untreated chlamydia?

If untreated, chlamydial infections can progress to serious reproductive and other health problems with both short-term and long-term consequences. Like the disease itself, the damage that chlamydia causes is often "silent."

STDs & Infertility In women, untreated infection can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID). This happens in about 10 to 15 percent of women with untreated chlamydia. Chlamydia can also cause fallopian tube infection without any symptoms. PID and "silent" infection in the upper genital tract can cause permanent damage to the fallopian tubes, uterus, and surrounding tissues. The damage can lead to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy (pregnancy outside the uterus). Chlamydia may also increase the chances of becoming infected with HIV, if exposed.

To help prevent the serious consequences of chlamydia, screening at least annually for chlamydia is recommended for all sexually active women age 25 years and younger. An annual screening test also is recommended for older women with risk factors for chlamydia (a new sex partner or multiple sex partners). All pregnant women should have a screening test for chlamydia.

Complications among men are rare. Infection sometimes spreads to the epididymis (the tube that carries sperm from the testis), causing pain, fever, and, rarely, sterility.

Rarely, genital chlamydial infection can cause arthritis that can be accompanied by skin lesions and inflammation of the eye and urethra (Reiter's syndrome).

How does chlamydia affect a pregnant woman and her baby?

In pregnant women, there is some evidence that untreated chlamydial infections can lead to premature delivery. Babies who are born to infected mothers can get chlamydial infections in their eyes and respiratory tracts. Chlamydia is a leading cause of early infant pneumonia and conjunctivitis (pink eye) in newborns.

How is chlamydia diagnosed?

There are laboratory tests to diagnose chlamydia. Some can be performed on urine, other tests require that a specimen be collected from a site such as the penis or cervix.

What is the treatment for chlamydia?

Chlamydia can be easily treated and cured with antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments. HIV-positive persons with chlamydia should receive the same treatment as those who are HIV negative.

All sex partners should be evaluated, tested, and treated. Persons with chlamydia should abstain from sexual intercourse for 7 days after single dose antibiotics or until completion of a 7-day course of antibiotics, to prevent spreading the infection to partners.

Women whose sex partners have not been appropriately treated are at high risk for re-infection. Having multiple infections increases a woman's risk of serious reproductive health complications, including infertility. Women and men with chlamydia should be retested about three months after treatment of an initial infection, regardless of whether they believe that their sex partners were treated.

How can chlamydia be prevented?

The surest way to avoid transmission of STDs 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.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia.

CDC recommends yearly chlamydia testing of all sexually active women age 25 or younger, older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women. An appropriate sexual risk assessment by a health care provider should always be conducted and may indicate more frequent screening for some women.

Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles could mean an STD infection. If a woman or man has any of these symptoms, they should stop having sex and consult a health care provider immediately. Treating STDs early in women can prevent PID. Women and men who are told they have an STD and are treated for it should notify all of their recent sex partners (sex partners within the preceding 60 days) so they can see a health care provider and be evaluated for STDs. Sexual activity should not resume until all sex partners have been examined and, if necessary, treated.

Where can I get more information?

Division of STD Prevention (DSTDP)
Centers for Disease Control and Prevention
http://www.cdc.gov/std

CDC National Prevention Information Network (NPIN)
1-800-458-5231
E-mail: [email protected]
http://www.cdcnpin.org

Sources

Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR 2006;55(No. RR-11).

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services, November 2009.

SD Datta et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. 2007:147:89-96.

Stamm W E. Chlamydia trachomatis infections of the adult. In: K. Holmes, P. Sparling, P. Mardh et al (eds). Sexually Transmitted Diseases, 3rd edition. New York: McGraw-Hill, 1999, 407-422.

Weinstock H, Berman S, Cates W. Sexually transmitted disease among American youth: Incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004; 36: 6-10.

Source: CDC - National Center for HIV, STD and TB Prevention
Page last updated: August 17, 2011

Reviewed by athealth on February 8, 2014.

Why is this choice so important?

Finding a therapist is important. Therapy is a collaborative process, so finding the right match-someone with whom you have a sense of rapport-is critical. After you find someone, keep in mind that therapy is work and sometimes can be painful. However, it also can be rewarding and life changing.

Can a therapist share what I have said during therapy?

All mental health professionals are ethically bound to keep what you say during therapy confidential. However, therapists are also bound by law to report information such as threats to blow up a building or to harm another person, like child abuse, for example.

What are the steps for choosing a therapist?

• See your primary care physician to rule out a medical cause of your problems. If your thyroid is "sluggish," for example, your symptoms-such as loss of appetite and fatigue-could be mistaken for depression.
• After you know your problems are not caused by a medical condition, find out what the mental health coverage is under your insurance policy or through Medicaid/Medicare.
• Get two or three referrals before making an appointment. Specify age, sex, race, or religious background if those characteristics are important to you.
• Call to find out about appointment availability, location, and fees. Ask the receptionist:
  • Does the mental health professional offer a sliding-scale fee based on income?
  • Does he or she accept your health insurance or Medicaid/Medicare?
  • Make sure the therapist has experience helping people whose problems are similar to yours. You may want to ask the receptionist about the therapist's expertise, education, and number of years in practice.
  • If you are satisfied with the answers, make an appointment.
  • During your first visit, describe those feelings and problems that led you to seek help. Find out:
    • What kind of therapy/treatment program he or she recommends;
    • Whether it has proven effective for dealing with problems such as yours;
    • What the benefits and side effects are;
    • How much therapy the mental health professional recommends; and
    • Whether he or she is willing to coordinate your care with another practitioner if you are personally interested in exploring credible alternative therapies, such as acupuncture.
    • Be sure the psychotherapist does not take a "cookie cutter" approach to your treatment-what works for one person with major depression does not necessarily work for another. Different psychotherapies and medications are tailored to meet specific needs.
    • Although the role of a therapist is not to be a friend, rapport is a critical element of successful therapy. After your initial visit, take some time to explore how you felt about the therapist.
    • If the answers to these questions and others you come up with are "yes," schedule another appointment to begin the process of working together to understand and overcome your problems. If the answers to most of these questions are "no," call another mental health professional from your referral list and schedule another appointment.

What is the difference between psychiatrists and clinical social workers?

• Two kinds of therapists warrant special note: psychiatrists and clinical social workers. Psychiatrists are medical doctors and can prescribe medication. Clinical social workers are trained in client-centered advocacy and can assist you with information, referral, and direct help in dealing with local, State, or Federal government agencies. As a result, they often serve as case managers to help people "navigate the system." Clinical social workers and many other mental health professionals cannot write prescriptions. However, nurse practitioners that specialize in psychiatry and mental health can prescribe medication in most states. And, under a new law, psychologists in New Mexico can prescribe medications after receiving training (New Mexico State Legislature, 2002).Source: Substance Abuse and Mental Health Services Administration
  April 2003

  Reviewed by athealth.com on February 1, 2014

General Information

Chronic fatigue syndrome, or CFS, is a devastating and complex disorder characterized by overwhelming fatigue that is not improved by bed rest and that may be worsened by physical or mental activity. People with CFS most often function at a significantly lower level of activity than they were capable of before the onset of illness.

In addition to these key defining characteristics, patients report various nonspecific symptoms, including weakness, muscle pain, impaired memory and/or mental concentration, insomnia, and post-exertional fatigue lasting more than 24 hours. In some cases, CFS can persist for years.

The cause or causes of CFS have not been identified and no specific diagnostic tests are available. Moreover, since many illnesses have incapacitating fatigue as a symptom, care must be taken to exclude other known and often treatable conditions before a diagnosis of CFS is made.

Case Definition

As of today, the cause or causes of CFS have not been identified and no specific diagnostic tests are available. Therefore, in order to be diagnosed with chronic fatigue syndrome, a patient must satisfy two criteria:

• Have severe chronic fatigue for at least 6 months or longer that is not relieved by rest and not due to medical or psychiatric conditions associated with fatigue as excluded by clinical diagnosis; and
• Concurrently have four or more of the following symptoms:
  • self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities
  • sore throat that's frequent or recurring
  • tender cervical or axillary lymph nodes
  • muscle pain
  • multi-joint pain without swelling or redness
  • headaches of a new type, pattern, or severity
  • unrefreshing sleep and
  • post-exertional malaise (extreme, prolonged exhaustion and sickness following physical or mental activity) lasting more than 24 hours.

The fatigue and impaired memory or concentration must have impaired normal daily activities, along with other symptoms that must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.

Causes of CFS

The cause or causes of CFS remain unknown, despite a vigorous search. While a single cause for CFS may yet be identified, another possibility is that CFS represents a common endpoint of disease resulting from multiple sudden causes. Some of the possible causes of CFS might be due to infectious agents, immunological dysfunction, stress activating the hypothalamic-pituitary adrenal (HPA) axis, neurally mediated hypotension, and/or nutritional deficiency.

Symptoms of CFS

The primary symptoms of CFS are severe fatigue, weakening that is not improved by bed rest and may be worsened with physical or mental activity. It is an all-encompassing fatigue that results in dramatic decline in both activity level and stamina.

The fatigue of CFS is accompanied by characteristic symptoms lasting at least 6 months. These symptoms include:

• self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities
• sore throat that's frequent or recurring
• tender cervical (neck) or axillary (armpit) lymph nodes
• muscle pain
• multi-joint pain without swelling or redness
• headaches of a new type, pattern, or severity
• unrefreshing sleep and
• post-exertional malaise (extreme, prolonged exhaustion and sickness following physical or mental activity) lasting more than 24 hours.

The symptoms listed above are the symptoms used to diagnose this illness. However, many CFS patients may experience other symptoms, including irritable bowel, depression or psychological problems, chills and night sweats, visual disturbances, allergies or sensitivities to foods, odors, chemicals, medications, or noise, brain fog, difficulty maintaining upright position, dizziness, balance problems or fainting.

Diagnosis of CFS

Because there is no blood test, brain scan or other lab test to diagnose CFS, it is a diagnosis of exclusion. A health care professional will first take a detailed patient history, then a thorough physical and mental status examination. Next, a series of laboratory screening tests will be ordered to help identify or rule out other possible causes of symptoms. There may also be additional tests to follow up on results of the initial screening tests. A diagnosis of insufficient fatigue could be made if a patient has been fatigued for 6 months or more, but does not meet the symptom criteria for CFS.

Treatment of CFS

Managing chronic fatigue syndrome can be as complex as the illness itself. There is no cure yet, no prescription drugs have been developed specifically for CFS, and symptoms vary considerably over time. These factors complicate the treatment picture, which require patients and doctors to always monitor and change treatment strategies.

One key to managing CFS is each patient needs to work with a team of doctors and other health care practitioners, which might include mental health professionals, rehabilitation specialist, and physical or exercise therapists, to create an individualized treatment program. This program should be based on a combination of therapies that address coping techniques, symptoms and activity management.

Centers for Disease Control and Prevention
Last updated: October 15, 2010

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

Millions of Americans suffer from daily chronic pain. Some of the common medical conditions associated with chronic pain include back injury, reflex sympathetic dystrophy (RSD), fibromyalgia, neck injury, spinal cord injury, diabetes and multiple sclerosis. Chronic pain can be defined as pain that last for 6 months or more and causes a marked diminishment in social and/or occupational activities. Some traditional treatments for chronic pain include physical therapy, oral pain medication, pain patches, anti-inflammatory medications, steroid injections, nerve blocks and transcutaneous electrical nerve stimulation (TENS). Long term surgical treatment options may include implantation of an intrathecal pump or implantation of a dorsal column stimulator.

Individuals suffering with chronic pain often have difficulty obtaining and/or maintaining employment. They often need assistance with household chores. They may require assistance with daily hygiene and grooming. These individuals may become isolated because they are not able to attend social functions due to the pain. Relationships involving individuals with chronic can be strained due to increased irritability and fatigue. They often have feelings of depression, hopelessness, guilt, anxiety and shame related to their inability to function independently and contribute to their household as they may have once done. Pain medications, although often a necessary component of treatment, can have negative side effects such as stomach upset and fatigue. Pain medications can also impair an individual's memory, attention and other thinking skills. These factors can compound the overall medical condition and lead to despair.

Alternative treatments such as educating an individual about the mind body connection, training an individual to perform guided and self relaxation techniques or hypnosis and utilizing cognitive behavioral therapy to set measurable and realistic goals can significantly reduce chronic pain and the related negative emotions. These treatments often have little to no reported negative side effects and the benefit is often reported to be experienced immediately. Online, face to face and/or e-mail counseling can aid an individual in learning how to listen to their body and respond in a manner that promotes a release of negativity. Connecting with a psychotherapist trained in the treatment of chronic pain is an essential part of any pain management plan.

About the Author:

Cynthia Kindgren MS/LCPC, CHT, is certified by the national board for certified counselors and is a certified hypnotherapist. She is a Licensed Clinical Professional Counselor in the state of Illinois. She is also a member of the American Counseling Association, International Society For Mental Health Online, lllinois Counseling Association, and the Illinois Mental Health Association.

She assists individuals and their families in dealing with adjustment issues related to brain injury, stroke, spinal cord injury, multiple sclerosis, fibromyalgia, reflex sympathetic dystrophy (RSD) and numerous forms of chronic pain. For additional information, visit her Web site at http://www.bmnaonline.com/index.html

Page last reviewed by athealth.com on February 1, 2014