Depression always goes hand-in-hand with an eating disorder. Together the two rob a person of their happiness and self-worth, and easily wreak havoc on innocent lives. Unfortunately, we are living in a "pill society" and, more often than not, therapists tend to treat depression alone with drugs instead of with a more psychological basis and along with the eating disorder. It's amazing to look at the statistics and discover the multitudes of people who suffer from depression while this, just as with eating disorders, still appears to be an enigma to understanding. Hopefully the information contained here will help clear some of the fogginess of sadness away...

overview

Depression is not biased - it affects anyone at any race and age and economical standing. It can strike at any moment; it doesn't need a tragic incident to trigger onset. Over 19 million over age 18 are considered to be clinically depressed, or 1 out of 5 people in general society. Depression is so common that it is second only to heart disease in causing lost work days. More frighteningly so, untreated, depression is the number ONE cause of suicide (appx. 13,000 people died from suicide in '96 alone).

the.many.forms.of.depression

There are indeed three different kinds of depression - normal, mild, and then severe. I have found personally that those with eating disorders tend to range between having mild and severe depression.

normal.depression - This is a natural reaction to the loss of a loved one, one which has caused sadness, lethargy, and in serious cases, grief to the point of loss of appetite, insomnia, anger, obsessive thoughts about the lost person, and never ending guilt. What is different about normal depression from mild and severe cases is that most people eventually recover and return to their typical moods after encountering normal depression. When the moods of a person do not lift and instead continue, then mild depression is setting in.

mild.depression - When a person is chronically depressed, possesses low self-esteem, and has some symptoms of severe depression, then they are considered to have mild depression. With mild depression the person can still function through their daily life, but it is very hard for them and they are known as having "the blues." Many times the mildly depressed person has nothing to hold accountable for their change of moods. Doctors and therapists should carefully watch over a person with mild depression because often times the mild depression will start out this way, but eventually progress into severe depression.

I am the voice inside your head and I control you
I am the hate you try to hide and I control you
I am denial guilt and fear and I control you
I am the lie that you believe and I control you
I am the high you can't sustain and I control you
I am the truth from which you run and I control you
I take you where you want to go
I give you all you need to know
I drag you down, I use you up
Mr. Self Destruct-NIN

severe.depression - The person with this feels utterly hopeless and feels such great despair that they lose all interest in life, causing the person to be incapable of feeling pleasure. Sometimes the person will be unable to eat for days or be incapable to get out of bed. Trying to do these activities when severely depressed, the person feels anxious, irritable, agitated, and chronic indecisiveness. Sleep disturbances such as insomnia are not uncommon. Just as with mild depression, severe depression often does not set in after a traumatic incident or the loss of a loved one. However, the intense feelings of grief, guilt, and unworthiness are experienced just the same. Untreated, an estimated 25% of sufferers try to kill themselves after suffering for 5 years with this horrible mood disorder.

why.does.this.happen?

Often trying to figure out which triggered what (Did the eating disorder trigger the depression, or the other way around?) ends up being a game of whether the chicken or the egg came first, so I don't even bother. What's more important to me is finding the main trigger to the depression currently. Obviously the helplessness and hopelessness that comes from anorexia and bulimia is plenty enough to aggravate someone's moods. The person with the eating disorder feels helpless - they feel out of control, while desperately searching for control by starvation and/or purging. At the same time, they feel like failures for not losing enough weight and not doing it fast enough (making a twisted accomplishment). The current state of the medical community also doesn't host many rays of light, as it isn't uncommon for a severe case to be called "hopeless" and "incurable," or for a mis-understanding and mis-educated doctor to call someone with an eating disorder "selfish" and "manipulative." It's extremely hard to "think positively" and to "just read a few self-help books" and then magically, POOF, be ok. Depression doesn't work that way, and inevitably it is aggravated and made worse. The person may occasionally able to have a once in a blue moon GENUINE happy moment, but for the majority, they are down in the dumps (often believing they deserve to be there).

Along with an eating disorder triggering and aggravating depression, biological problems also affect mood disorders such as this. Studies on seratonin, also known as the "feel good" neurotransmitter, have caused some interesting findings to come up - some showing that you can be born with messed up levels and that alone can cause a 4 year old to be diagnosed as clinically depressed. The basics of seratonin are if it falls too low, depression and other complications occur, and starving and/or purging always messes up this chemical. Usually when someone with anorexia is in what is known as "starvation mode" (occurs generally when the weight has fallen below 98 pounds and the body just goes completely bonkers and manic), depression is almost solely biological. Some therapists even require that a patient's weight be raised up past 98 pounds before they will treat them for the eating disorder and/or depression because it is too hard to have the person think clearly at such a weight and condition that the body is in.

---

depression treatment

Just as with any additional disorder, depression MUST be treated along with the eating disorder. Often depression treatment includes Cognitive Behavioral Therapy (CBT) which identifies the ten forms of distorted thinking found in depression (see below). Besides CBT, there are many anti-depressants that are used. These include the famous Prozac, Zoloft, and Paxil. It is true that generally after a person is taken away cold turkey from their anti-depressant that they relapse back into old thinking patterns and the depression re-surfaces, however, when treated along with Cognitive Behavioral Therapy, most are able to be "weened" off of the anti-depressants without many problems. The key is to learn better rationalization techniques along with using the drug as just a little "booster," so that in the end you have learned how to rationalize and use logic for your problems well enough that you no longer need anti-depressants.

the.nine.forms.of.distorted.thinking

1. All-or-Nothing Thinking :
   This is the black or white thinking pattern. If the person is not perfect they are nothing and a total failure. If the victim gets an A- on a test it's the end of the world
2. Labeling :
   The person makes a mistake and instead of thinking that hey they made a mistake no big deal they label themselves names such as a failure or pathetic. Another example of this is having a parent yell at you for forgetting to do a chore. Instead of thinking that you'll remember next time you may label yourself totally worthless and because of that your parents don't love you now.
3. Over-generalization :
   This is when a person makes a slight blunder and believes they will never get it right. ("I relapsed again; I wont ever be able to recover.")
4. Mental Filtering :
   ED victims tend to do this quite a lot. Say a friend commented on a piece of art work but then added that one of the colors was a little off. Instead of remembering that 99% of the art work is great looking the person dwells on the negative part of what the friend said and filters out any positive remarks. Many times the ED victim will say that they are good for nothing and that no one gives them any positive remarks but they do not realize that any positive remarks that they have been given they have immediately dismissed.
5. Discounting the Positive :
   This thinking is when you do something well such as cooking a good meal and then when given positive remarks on it you immediately think things like "Well, anyone could have done it," or, "It wasn't that great..."
6. Jumping to Conclusions :
   You assume the worst based on no evidence. You decide that another person is reacting negatively to you. ("I know she didn't really mean it when she said I wasn't fat; she's lying just to be nice.")
7. Magnification:
   This is the exaggeration of importance of problems and minor annoyances. An example of this would be an eating disorder victim not exercising for a full hour and thinking that what he did before was worth nothing.
8. Emotional Reasoning :
   Ever confuse your emotions for reality? This is when the thoughts of 'I feel fat so therefore I am fat' come up. The self-demanding tip-off's include 'must', 'ought to', and 'have to'.
9. Personalizing the Blame :
   These thoughts are another very common trait among eating disorder victims. The person believes that things beyond his or her control are the victim's fault. ("I ate yesterday and that's why the plane crashed," or, "If I had gotten an A+ instead of an A then my mom wouldn't have a migraine today.")

Personally, I have found that a major key in helping rid depression is realizing that we all have limits and faults, but that that is OK, and that there are better ways of dealing with things than self-destruction. One particular quote has been especially helpful, and it goes a lil' something like this: Most depression or anxiety-producing events are not inherently awful. What makes them feel distressing is the way we react to them.

next: Eating Disorder Relapses: What to Do and How to Prevent Them
~ all peace, love and hope articles
~ eating disorders library
~ all articles on eating disorders

(sildenafil citrate) Tablets

Description
Pharmacology
Indications and Usage
Contraindications
Warnings
Precautions
Drug Interactions
Adverse Reactions
Overdose
Dosage
Supplied

DESCRIPTION

VIAGRA®, an oral therapy for erectile dysfunction, is the citrate salt of sildenafil, a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5).

Sildenafil citrate is designated chemically as 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1Hpyrazolo[ 4,3-d]pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citrate and has the following structural formula:

Sildenafil citrate is a white to off-white crystalline powder with a solubility of 3.5 mg/mL in water and a molecular weight of 666.7. VIAGRA (sildenafil citrate) is formulated as blue, film-coated rounded-diamond-shaped tablets equivalent to 25 mg, 50 mg and 100 mg of sildenafil for oral administration. In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD & C Blue #2 aluminum lake.

top

CLINICAL PHARMACOLOGY

Mechanism of Action

The physiologic mechanism of erection of the penis involves release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. NO then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP), producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood. Sildenafil has no direct relaxant effect on isolated human corpus cavernosum, but enhances the effect of nitric oxide (NO) by inhibiting phosphodiesterase type 5 (PDE5), which is responsible for degradation of cGMP in the corpus cavernosum. When sexual stimulation causes local release of NO, inhibition of PDE5 by sildenafil causes increased levels of cGMP in the corpus cavernosum, resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum. Sildenafil at recommended doses has no effect in the absence of sexual stimulation.

---

 

---

Studies in vitro have shown that sildenafil is selective for PDE5. Its effect is more potent on PDE5 than on other known phosphodiesterases (10-fold for PDE6, >80-fold for PDE1, >700-fold for PDE2, PDE3, PDE4, PDE7, PDE8, PDE9, PDE10, and PDE11). The approximately 4,000-fold selectivity for PDE5 versus PDE3 is important because PDE3 is involved in control of cardiac contractility. Sildenafil is only about 10-fold as potent for PDE5 compared to PDE6, an enzyme found in the retina which is involved in the phototransduction pathway of the retina. This lower selectivity is thought to be the basis for abnormalities related to color vision observed with higher doses or plasma levels (see Pharmacodynamics).

In addition to human corpus cavernosum smooth muscle, PDE5 is also found in lower concentrations in other tissues including platelets, vascular and visceral smooth muscle, and skeletal muscle. The inhibition of PDE5 in these tissues by sildenafil may be the basis for the enhanced platelet antiaggregatory activity of nitric oxide observed in vitro, an inhibition of platelet thrombus formation in vivo and peripheral arterial-venous dilatation in vivo.

Pharmacokinetics and Metabolism

VIAGRA is rapidly absorbed after oral administration, with absolute bioavailability of about 40%. Its pharmacokinetics are dose-proportional over the recommended dose range. It is eliminated predominantly by hepatic metabolism (mainly cytochrome P450 3A4) and is converted to an active metabolite with properties similar to the parent, sildenafil. The concomitant use of potent cytochrome P450 3A4 inhibitors (e.g., erythromycin, ketoconazole, itraconazole) as well as the nonspecific CYP inhibitor, cimetidine, is associated with increased plasma levels of sildenafil (see DOSAGE AND ADMINISTRATION). Both sildenafil and the metabolite have terminal half lives of about 4 hours.

Mean sildenafil plasma concentrations measured after the administration of a single oral dose of 100 mg to healthy male volunteers is depicted below:

Figure 1: Mean Sildenafil Plasma Concentrations in Healthy Male Volunteers.

Absorption and Distribution: VIAGRA is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to 120 minutes (median 60 minutes) of oral dosing in the fasted state. When VIAGRA is taken with a high fat meal, the rate of absorption is reduced, with a mean delay in Tmax of 60 minutes and a mean reduction in Cmax of 29%. The mean steady state volume of distribution (Vss) for sildenafil is 105 L, indicating distribution into the tissues. Sildenafil and its major circulating N-desmethyl metabolite are both approximately 96% bound to plasma proteins. Protein binding is independent of total drug concentrations.

Based upon measurements of sildenafil in semen of healthy volunteers 90 minutes after dosing, less than 0.001% of the administered dose may appear in the semen of patients.

Metabolism and Excretion: Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic microsomal isoenzymes. The major circulating metabolite results from N-desmethylation of sildenafil, and is itself further metabolized. This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency for PDE5 approximately 50% of the parent drug. Plasma concentrations of this metabolite are approximately 40% of those seen for sildenafil, so that the metabolite accounts for about 20% of sildenafil's pharmacologic effects.

After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the feces (approximately 80% of administered oral dose) and to a lesser extent in the urine (approximately 13% of the administered oral dose). Similar values for pharmacokinetic parameters were seen in normal volunteers and in the patient population, using a population pharmacokinetic approach.

Pharmacokinetics in Special Populations

Geriatrics: Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, with free plasma concentrations approximately 40% greater than those seen in healthy younger volunteers (18-45 years).

Renal Insufficiency: In volunteers with mild (CLcr=50-80 mL/min) and moderate (CLcr=30-49 mL/min) renal impairment, the pharmacokinetics of a single oral dose of VIAGRA (50 mg) were not altered. In volunteers with severe (CLcr=<30 mL/min) renal impairment, sildenafil clearance was reduced, resulting in approximately doubling of AUC and Cmax compared to age-matched volunteers with no renal impairment.

Hepatic Insufficiency: In volunteers with hepatic cirrhosis (Child-Pugh A and B), sildenafil clearance was reduced, resulting in increases in AUC (84%) and Cmax (47%) compared to age-matched volunteers with no hepatic impairment.

Therefore, age >65, hepatic impairment and severe renal impairment are associated with increased plasma levels of sildenafil. A starting oral dose of 25 mg should be considered in those patients (see DOSAGE AND ADMINISTRATION).

Pharmacodynamics

Effects of VIAGRA on Erectile Response: In eight double-blind, placebo-controlled crossover studies of patients with either organic or psychogenic erectile dysfunction, sexual stimulation resulted in improved erections, as assessed by an objective measurement of hardness and duration of erections (RigiScan®), after VIAGRA administration compared with placebo. Most studies assessed the efficacy of VIAGRA approximately 60 minutes post dose. The erectile response, as assessed by RigiScan®, generally increased with increasing sildenafil dose and plasma concentration. The time course of effect was examined in one study, showing an effect for up to 4 hours but the response was diminished compared to 2 hours.

Effects of VIAGRA on Blood Pressure: Single oral doses of sildenafil (100 mg) administered to healthy volunteers produced decreases in supine blood pressure (mean maximum decrease in systolic/diastolic blood pressure of 8.4/5.5 mmHg). The decrease in blood pressure was most notable approximately 1-2 hours after dosing, and was not different than placebo at 8 hours. Similar effects on blood pressure were noted with 25 mg, 50 mg and 100 mg of VIAGRA, therefore the effects are not related to dose or plasma levels within this dosage range. Larger effects were recorded among patients receiving concomitant nitrates (see CONTRAINDICATIONS).

Figure 2: Mean Change from Baseline in Sitting Systolic Blood Pressure, Healthy Volunteers.

Effects of VIAGRA on Cardiac Parameters: Single oral doses of sildenafil up to 100 mg produced no clinically relevant changes in the ECGs of normal male volunteers.

Studies have produced relevant data on the effects of VIAGRA on cardiac output. In one small, open-label, uncontrolled, pilot study, eight patients with stable ischemic heart disease underwent Swan-Ganz catheterization. A total dose of 40 mg sildenafil was administered by four intravenous infusions.

The results from this pilot study are shown in Table 1; the mean resting systolic and diastolic blood pressures decreased by 7% and 10% compared to baseline in these patients. Mean resting values for right atrial pressure, pulmonary artery pressure, pulmonary artery occluded pressure and cardiac output decreased by 28%, 28%, 20% and 7% respectively. Even though this total dosage produced plasma sildenafil concentrations which were approximately 2 to 5 times higher than the mean maximum plasma concentrations following a single oral dose of 100 mg in healthy male volunteers, the hemodynamic response to exercise was preserved in these patients.

TABLE 1. HEMODYNAMIC DATA IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE AFTER IV ADMINISTRATION OF 40 MG SILDENAFIL

Means ± SD	At rest				After 4 minutes of exercise
	n	Baseline (B2)	n	Sildenafil (D1)	n	Baseline	n	Sildenafil
PAOP (mmHg)	8	8.1 ± 5.1	8	6.5 ± 4.3	8	36.0 ± 13.7	8	27.8 ± 15.3
Mean PAP (mmHg)	8	16.7 ± 4	8	12.1 ± 3.9	8	39.4 ± 12.9	8	31.7 ± 13.2
Mean RAP (mmHg)	7	5.7 ± 3.7	8	4.1 ± 3.7	-	-	-	-
Systolic SAP (mmHg)	8	150.4 ± 12.4	8	140.6 ± 16.5	8	199.5 ± 37.4	8	187.8 ± 30.0
Diastolic SAP (mmHg)	8	73.6 ± 7.8	8	65.9 ± 10	8	84.6 ± 9.7	8	79.5 ± 9.4
Cardiac output (L/min)	8	5.6 ± 0.9	8	5.2 ± 1.1	8	11.5 ± 2.4	8	10.2 ± 3.5
Heart rate (bpm)	8	67 ± 11.1	8	66.9 ± 12	8	101.9 ± 11.6	8	99.0 ± 20.4

 

In a double-blind study, 144 patients with erectile dysfunction and chronic stable angina limited by exercise, not receiving chronic oral nitrates, were randomized to a single dose of placebo or VIAGRA 100 mg 1 hour prior to exercise testing. The primary endpoint was time to limiting angina in the evaluable cohort. The mean times (adjusted for baseline) to onset of limiting angina were 423.6 and 403.7 seconds for sildenafil (N=70) and placebo, respectively. These results demonstrated that the effect of VIAGRA on the primary endpoint was statistically non-inferior to placebo.

Effects of VIAGRA on Vision: At single oral doses of 100 mg and 200 mg, transient dose-related impairment of color discrimination (blue/green) was detected using the Farnsworth-Munsell 100-hue test, with peak effects near the time of peak plasma levels. This finding is consistent with the inhibition of PDE6, which is involved in phototransduction in the retina. An evaluation of visual function at doses up to twice the maximum recommended dose revealed no effects of VIAGRA on visual acuity, intraocular pressure, or pupillometry.

Clinical Studies

In clinical studies, VIAGRA was assessed for its effect on the ability of men with erectile dysfunction (ED) to engage in sexual activity and in many cases specifically on the ability to achieve and maintain an erection sufficient for satisfactory sexual activity. VIAGRA was evaluated primarily at doses of 25 mg, 50 mg and 100 mg in 21 randomized, double-blind, placebo-controlled trials of up to 6 months in duration, using a variety of study designs (fixed dose, titration, parallel, crossover). VIAGRA was administered to more than 3,000 patients aged 19 to 87 years, with ED of various etiologies (organic, psychogenic, mixed) with a mean duration of 5 years. VIAGRA demonstrated statistically significant improvement compared to placebo in all 21 studies. The studies that established benefit demonstrated improvements in success rates for sexual intercourse compared with placebo.

The effectiveness of VIAGRA was evaluated in most studies using several assessment instruments. The primary measure in the principal studies was a sexual function questionnaire (the International Index of Erectile Function - IIEF) administered during a 4-week treatment-free run-in period, at baseline, at follow-up visits, and at the end of double-blind, placebo-controlled, at-home treatment. Two of the questions from the IIEF served as primary study endpoints; categorical responses were elicited to questions about (1) the ability to achieve erections sufficient for sexual intercourse and (2) the maintenance of erections after penetration. The patient addressed both questions at the final visit for the last 4 weeks of the study. The possible categorical responses to these questions were (0) no attempted intercourse, (1) never or almost never, (2) a few times, (3) sometimes, (4) most times, and (5) almost always or always. Also collected as part of the IIEF was information about other aspects of sexual function, including information on erectile function, orgasm, desire, satisfaction with intercourse, and overall sexual satisfaction. Sexual function data were also recorded by patients in a daily diary. In addition, patients were asked a global efficacy question and an optional partner questionnaire was administered.

The effect on one of the major end points, maintenance of erections after penetration, is shown in Figure 3, for the pooled results of 5 fixed-dose, dose-response studies of greater than one month duration, showing response according to baseline function. Results with all doses have been pooled, but scores showed greater improvement at the 50 and 100 mg doses than at 25 mg. The pattern of responses was similar for the other principal question, the ability to achieve an erection sufficient for intercourse. The titration studies, in which most patients received 100 mg, showed similar results. Figure 3 shows that regardless of the baseline levels of function, subsequent function in patients treated with VIAGRA was better than that seen in patients treated with placebo. At the same time, on-treatment function was better in treated patients who were less impaired at baseline.

 

Figure 3. Effect of VIAGRA and Placebo on
Maintenance of Erection by Baseline Score.

The frequency of patients reporting improvement of erections in response to a global question in four of the randomized, double-blind, parallel, placebo-controlled fixed dose studies (1797 patients) of 12 to 24 weeks duration is shown in Figure 4. These patients had erectile dysfunction at baseline that was characterized by median categorical scores of 2 (a few times) on principal IIEF questions. Erectile dysfunction was attributed to organic (58%; generally not characterized, but including diabetes and excluding spinal cord injury), psychogenic (17%), or mixed (24%) etiologies. Sixty-three percent, 74%, and 82% of the patients on 25 mg, 50 mg and 100 mg of VIAGRA, respectively, reported an improvement in their erections, compared to 24% on placebo. In the titration studies (n=644) (with most patients eventually receiving 100 mg), results were similar.

Figure 4. Percentage of Patients Reporting an Improvement in Erections.

The patients in studies had varying degrees of ED. One-third to one-half of the subjects in these studies reported successful intercourse at least once during a 4-week, treatment-free run-in period.

In many of the studies, of both fixed dose and titration designs, daily diaries were kept by patients. In these studies, involving about 1600 patients, analyses of patient diaries showed no effect of VIAGRA on rates of attempted intercourse (about 2 per week), but there was clear treatment-related improvement in sexual function: per patient weekly success rates averaged 1.3 on 50-100 mg of VIAGRA vs 0.4 on placebo; similarly, group mean success rates (total successes divided by total attempts) were about 66% on VIAGRA vs about 20% on placebo.

During 3 to 6 months of double-blind treatment or longer-term (1 year), open-label studies, few patients withdrew from active treatment for any reason, including lack of effectiveness. At the end of the long-term study, 88% of patients reported that VIAGRA improved their erections.

Men with untreated ED had relatively low baseline scores for all aspects of sexual function measured (again using a 5-point scale) in the IIEF. VIAGRA improved these aspects of sexual function: frequency, firmness and maintenance of erections; frequency of orgasm; frequency and level of desire; frequency, satisfaction and enjoyment of intercourse; and overall relationship satisfaction.

One randomized, double-blind, flexible-dose, placebo-controlled study included only patients with erectile dysfunction attributed to complications of diabetes mellitus (n=268). As in the other titration studies, patients were started on 50 mg and allowed to adjust the dose up to 100 mg or down to 25 mg of VIAGRA; all patients, however, were receiving 50 mg or 100 mg at the end of the study. There were highly statistically significant improvements on the two principal IIEF questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) on VIAGRA compared to placebo. On a global improvement question, 57% of VIAGRA patients reported improved erections versus 10% on placebo. Diary data indicated that on VIAGRA, 48% of intercourse attempts were successful versus 12% on placebo.

One randomized, double-blind, placebo-controlled, crossover, flexible-dose (up to 100 mg) study of patients with erectile dysfunction resulting from spinal cord injury (n=178) was conducted. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. On a global improvement question, 83% of patients reported improved erections on VIAGRA versus 12% on placebo. Diary data indicated that on VIAGRA, 59% of attempts at sexual intercourse were successful compared to 13% on placebo.

Across all trials, VIAGRA improved the erections of 43% of radical prostatectomy patients compared to 15% on placebo.

Subgroup analyses of responses to a global improvement question in patients with psychogenic etiology in two fixed-dose studies (total n=179) and two titration studies (total n=149) showed 84% of VIAGRA patients reported improvement in erections compared with 26% of placebo. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. Diary data in two of the studies (n=178) showed rates of successful intercourse per attempt of 70% for VIAGRA and 29% for placebo.

A review of population subgroups demonstrated efficacy regardless of baseline severity, etiology, race and age. VIAGRA was effective in a broad range of ED patients, including those with a history of coronary artery disease, hypertension, other cardiac disease, peripheral vascular disease, diabetes mellitus, depression, coronary artery bypass graft (CABG), radical prostatectomy, transurethral resection of the prostate (TURP) and spinal cord injury, and in patients taking antidepressants/antipsychotics and antihypertensives/diuretics.

Analysis of the safety database showed no apparent difference in the side effect profile in patients taking VIAGRA with and without antihypertensive medication. This analysis was performed retrospectively, and was not powered to detect any pre-specified difference in adverse reactions.

INDICATION AND USAGE

VIAGRA is indicated for the treatment of erectile dysfunction.

CONTRAINDICATIONS

Consistent with its known effects on the nitric oxide/cGMP pathway (see CLINICAL PHARMACOLOGY), VIAGRA was shown to potentiate the hypotensive effects of nitrates, and its administration to patients who are using organic nitrates, either regularly and/or intermittently, in any form is therefore contraindicated.

After patients have taken VIAGRA, it is unknown when nitrates, if necessary, can be safely administered. Based on the pharmacokinetic profile of a single 100 mg oral dose given to healthy normal volunteers, the plasma levels of sildenafil at 24 hours post dose are approximately 2 ng/mL (compared to peak plasma levels of approximately 440 ng/mL) (see CLINICAL PHARMACOLOGY: Pharmacokinetics and Metabolism). In the following patients: age >65, hepatic impairment (e.g., cirrhosis), severe renal impairment (e.g., creatinine clearance <30 mL/min), and concomitant use of potent cytochrome P450 3A4 inhibitors (erythromycin), plasma levels of sildenafil at 24 hours post dose have been found to be 3 to 8 times higher than those seen in healthy volunteers. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely coadministered at this time point.

VIAGRA is contraindicated in patients with a known hypersensitivity to any component of the tablet.

WARNINGS

There is a potential for cardiac risk of sexual activity in patients with preexisting cardiovascular disease. Therefore, treatments for erectile dysfunction, including VIAGRA, should not be generally used in men for whom sexual activity is inadvisable because of their underlying cardiovascular status.

VIAGRA has systemic vasodilatory properties that resulted in transient decreases in supine blood pressure in healthy volunteers (mean maximum decrease of 8.4/5.5 mmHg), (see CLINICAL PHARMACOLOGY: Pharmacodynamics). While this normally would be expected to be of little consequence in most patients, prior to prescribing VIAGRA, physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects, especially in combination with sexual activity.

Patients with the following underlying conditions can be particularly sensitive to the actions of vasodilators including VIAGRA - those with left ventricular outflow obstruction (e.g. aortic stenosis, idiopathic hypertrophic subaortic stenosis) and those with severely impaired autonomic control of blood pressure.

There is no controlled clinical data on the safety or efficacy of VIAGRA in the following groups; if prescribed, this should be done with caution.

• Patients who have suffered a myocardial infarction, stroke, or life-threatening arrhythmia within the last 6 months;
• Patients with resting hypotension (BP 170/110);
• Patients with cardiac failure or coronary artery disease causing unstable angina;
• Patients with retinitis pigmentosa (a minority of these patients have genetic disorders of retinal phosphodiesterases).

Prolonged erection greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency could result.

The concomitant administration of the protease inhibitor ritonavir substantially increases serum concentrations of sildenafil (11-fold increase in AUC). If VIAGRA is prescribed to patients taking ritonavir, caution should be used. Data from subjects exposed to high systemic levels of sildenafil are limited. Visual disturbances occurred more commonly at higher levels of sildenafil exposure. Decreased blood pressure, syncope, and prolonged erection were reported in some healthy volunteers exposed to high doses of sildenafil (200-800 mg). To decrease the chance of adverse events in patients taking ritonavir, a decrease in sildenafil dosage is recommended (see Drug Interactions, ADVERSE REACTIONS and DOSAGE AND ADMINISTRATION).

PRECAUTIONS

General

The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment.

Before prescribing VIAGRA, it is important to note the following:

Patients on multiple antihypertensive medications were included in the pivotal clinical trials for VIAGRA. In a separate drug interaction study, when amlodipine, 5 mg or 10 mg, and VIAGRA, 100 mg were orally administered concomitantly to hypertensive patients mean additional blood pressure reduction of 8 mmHg systolic and 7 mmHg diastolic were noted (see Drug Interactions).

When the alpha blocker doxazosin (4 mg) and VIAGRA (25 mg) were administered simultaneously to patients with benign prostatic hyperplasia (BPH), mean additional reductions of supine blood pressure of 7 mmHg systolic and 7 mmHg diastolic were observed. When higher doses of VIAGRA and doxazosin (4 mg) were administered simultaneously, there were infrequent reports of patients who experienced symptomatic postural hypotension within 1 to 4 hours of dosing. Simultaneous administration of VIAGRA to patients taking alpha-blocker therapy may lead to symptomatic hypotension in some patients. Therefore, VIAGRA doses above 25 mg should not be taken within 4 hours of taking an alpha-blocker

The safety of VIAGRA is unknown in patients with bleeding disorders and patients with active peptic ulceration.

VIAGRA should be used with caution in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anemia, multiple myeloma, or leukemia).

The safety and efficacy of combinations of VIAGRA with other treatments for erectile dysfunction have not been studied. Therefore, the use of such combinations is not recommended.

In humans, VIAGRA has no effect on bleeding time when taken alone or with aspirin. In vitro studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium nitroprusside (a nitric oxide donor). The combination of heparin and VIAGRA had an additive effect on bleeding time in the anesthetized rabbit, but this interaction has not been studied in humans.

Information for Patients

Physicians should discuss with patients the contraindication of VIAGRA with regular and/or intermittent use of organic nitrates.

Physicians should discuss with patients the potential cardiac risk of sexual activity in patients with preexisting cardiovascular risk factors. Patients who experience symptoms (e.g., angina pectoris, dizziness, nausea) upon initiation of sexual activity should be advised to refrain from further activity and should discuss the episode with their physician.

Physicians should advise patients to stop use of all PDE5 inhibitors, including VIAGRA, and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, that has been reported rarely post-marketing in temporal association with the use of all PDE5 inhibitors. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors. Physicians should also discuss with patients the increased risk of NAION in individuals who have already experienced NAION in one eye, including whether such individuals could be adversely affected by use of vasodilators, such as PDE5 inhibitors (see POSTMARKETING EXPERIENCE/Special Senses).

Physicians should warn patients that prolonged erections greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency may result.

Physicians should advise patients that simultaneous administration of VIAGRA doses above 25 mg and an alpha-blocker may lead to symptomatic hypotension in some patients. Therefore, VIAGRA doses above 25 mg should not be taken within four hours of taking an alpha-blocker.

The use of VIAGRA offers no protection against sexually transmitted diseases. Counseling of patients about the protective measures necessary to guard against sexually transmitted diseases, including the Human Immunodeficiency Virus (HIV), may be considered.

Drug Interactions

Effects of Other Drugs on VIAGRA

In vitro studies: Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil clearance.

In vivo studies: Cimetidine (800 mg), a nonspecific CYP inhibitor, caused a 56% increase in plasma sildenafil concentrations when coadministered with VIAGRA (50 mg) to healthy volunteers.

When a single 100 mg dose of VIAGRA was administered with erythromycin, a specific CYP3A4 inhibitor, at steady state (500 mg bid for 5 days), there was a 182% increase in sildenafil systemic exposure (AUC). In addition, in a study performed in healthy male volunteers, coadministration of the HIV protease inhibitor saquinavir, also a CYP3A4 inhibitor, at steady state (1200 mg tid) with VIAGRA (100 mg single dose) resulted in a 140% increase in sildenafil Cmax and a 210% increase in sildenafil AUC. VIAGRA had no effect on saquinavir pharmacokinetics. Stronger CYP3A4 inhibitors such as ketoconazole or itraconazole would be expected to have still greater effects, and population data from patients in clinical trials did indicate a reduction in sildenafil clearance when it was coadministered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, or cimetidine) (see DOSAGE AND ADMINISTRATION).

In another study in healthy male volunteers, coadministration with the HIV protease inhibitor ritonavir, which is a highly potent P450 inhibitor, at steady state (500 mg bid) with VIAGRA (100 mg single dose) resulted in a 300% (4-fold) increase in sildenafil Cmax and a 1000% (11-fold) increase in sildenafil plasma AUC. At 24 hours the plasma levels of sildenafil were still approximately 200 ng/mL, compared to approximately 5 ng/mL when sildenafil was dosed alone. This is consistent with ritonavir's marked effects on a broad range of P450 substrates. VIAGRA had no effect on ritonavir pharmacokinetics (see DOSAGE AND ADMINISTRATION).

Although the interaction between other protease inhibitors and sildenafil has not been studied, their concomitant use is expected to increase sildenafil levels.

It can be expected that concomitant administration of CYP3A4 inducers, such as rifampin, will decrease plasma levels of sildenafil.

Single doses of antacid (magnesium hydroxide/aluminum hydroxide) did not affect the bioavailability of VIAGRA.

Pharmacokinetic data from patients in clinical trials showed no effect on sildenafil pharmacokinetics of CYP2C9 inhibitors (such as tolbutamide, warfarin), CYP2D6 inhibitors (such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related diuretics, ACE inhibitors, and calcium channel blockers. The AUC of the active metabolite, N-desmethyl sildenafil, was increased 62% by loop and potassium-sparing diuretics and 102% by nonspecific beta-blockers. These effects on the metabolite are not expected to be of clinical consequence.

Effects of VIAGRA on Other Drugs

In vitro studies: Sildenafil is a weak inhibitor of the cytochrome P450 isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4 (IC50 >150 mM). Given sildenafil peak plasma concentrations of approximately 1 mM after recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these isoenzymes.

In vivo studies: When VIAGRA 100 mg oral was coadministered with amlodipine, 5 mg or 10 mg oral, to hypertensive patients, the mean additional reduction on supine blood pressure was 8 mmHg systolic and 7 mmHg diastolic.

No significant interactions were shown with tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolized by CYP2C9.

VIAGRA (50 mg) did not potentiate the increase in bleeding time caused by aspirin (150 mg).

VIAGRA (50 mg) did not potentiate the hypotensive effect of alcohol in healthy volunteers with mean maximum blood alcohol levels of 0.08%.

In a study of healthy male volunteers, sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors, saquinavir and ritonavir, both of which are CYP3A4 substrates.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Sildenafil was not carcinogenic when administered to rats for 24 months at a dose resulting in total systemic drug exposure (AUCs) for unbound sildenafil and its major metabolite of 29- and 42-times, for male and female rats, respectively, the exposures observed in human males given the Maximum Recommended Human Dose (MRHD) of 100 mg. Sildenafil was not carcinogenic when administered to mice for 18-21 months at dosages up to the Maximum Tolerated Dose (MTD) of 10 mg/kg/day, approximately 0.6 times the MRHD on a mg/m2 basis.

Sildenafil was negative in in vitro bacterial and Chinese hamster ovary cell assays to detect mutagenicity, and in vitro human lymphocytes and in vivo mouse micronucleus assays to detect clastogenicity.

There was no impairment of fertility in rats given sildenafil up to 60 mg/kg/day for 36 days to females and 102 days to males, a dose producing an AUC value of more than 25 times the human male AUC.

There was no effect on sperm motility or morphology after single 100 mg oral doses of VIAGRA in healthy volunteers.

Pregnancy, Nursing Mothers and Pediatric Use

VIAGRA is not indicated for use in newborns, children, or women.

Pregnancy Category B. No evidence of teratogenicity, embryotoxicity or fetotoxicity was observed in rats and rabbits which received up to 200 mg/kg/day during organogenesis. These doses represent, respectively, about 20 and 40 times the MRHD on a mg/m2 basis in a 50 kg subject. In the rat pre- and postnatal development study, the no observed adverse effect dose was 30 mg/kg/day given for 36 days. In the nonpregnant rat the AUC at this dose was about 20 times human AUC. There are no adequate and well-controlled studies of sildenafil in pregnant women.

Geriatric Use: Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil (see CLINICAL PHARMACOLOGY: Pharmacokinetics in Special Populations). Since higher plasma levels may increase both the efficacy and incidence of adverse events, a starting dose of 25 mg should be considered (see DOSAGE AND ADMINISTRATION).

ADVERSE REACTIONS

PRE-MARKETING EXPERIENCE:

VIAGRA was administered to over 3700 patients (aged 19-87 years) during clinical trials worldwide. Over 550 patients were treated for longer than one year.

In placebo-controlled clinical studies, the discontinuation rate due to adverse events for VIAGRA (2.5%) was not significantly different from placebo (2.3%). The adverse events were generally transient and mild to moderate in nature.

In trials of all designs, adverse events reported by patients receiving VIAGRA were generally similar. In fixed-dose studies, the incidence of some adverse events increased with dose. The nature of the adverse events in flexible-dose studies, which more closely reflect the recommended dosage regimen, was similar to that for fixed-dose studies.

When VIAGRA was taken as recommended (on an as-needed basis) in flexible-dose, placebo-controlled clinical trials, the following adverse events were reported:

TABLE 2. ADVERSE EVENTS REPORTED BY ³2% OF PATIENTS TREATED WITH VIAGRA AND MORE FREQUENT ON DRUG THAN PLACEBO IN PRN FLEXIBLE-DOSE PHASE II/III STUDIES

Adverse Event	Percentage of Patients Reporting Event
	VIAGRA	PLACEBO
	N=734	N=725
Headache	16%	4%
Flushing	10%	1%
Dyspepsia	7%	2%
Nasal Congestion	4%	2%
Urinary Tract Infection *	3%	2%
Abnormal Vision	3%	0%
Diarrhea	3%	1%
Dizziness	2%	1%
Rash	2%	1%

* Abnormal Vision: Mild and transient, predominantly color tinge to vision, but also increased sensitivity to light or blurred vision. In these studies, only one patient discontinued due to abnormal vision.

Other adverse reactions occurred at a rate of >2%, but equally common on placebo: respiratory tract infection, back pain, flu syndrome, and arthralgia.

In fixed-dose studies, dyspepsia (17%) and abnormal vision (11%) were more common at 100 mg than at lower doses. At doses above the recommended dose range, adverse events were similar to those detailed above but generally were reported more frequently.

The following events occurred in <2% of patients in controlled clinical trials; a causal relationship to VIAGRA is uncertain. Reported events include those with a plausible relation to drug use; omitted are minor events and reports too imprecise to be meaningful:

Body as a whole: face edema, photosensitivity reaction, shock, asthenia, pain, chills, accidental fall, abdominal pain, allergic reaction, chest pain, accidental injury.

Cardiovascular: angina pectoris, AV block, migraine, syncope, tachycardia, palpitation, hypotension, postural hypotension, myocardial ischemia, cerebral thrombosis, cardiac arrest, heart failure, abnormal electrocardiogram, cardiomyopathy.

Digestive: vomiting, glossitis, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, dry mouth, liver function tests abnormal, rectal hemorrhage, gingivitis.

Hemic and Lymphatic: anemia and leukopenia.

Metabolic and Nutritional: thirst, edema, gout, unstable diabetes, hyperglycemia, peripheral edema, hyperuricemia, hypoglycemic reaction, hypernatremia.

Musculoskeletal: arthritis, arthrosis, myalgia, tendon rupture, tenosynovitis, bone pain, myasthenia, synovitis.

Nervous: ataxia, hypertonia, neuralgia, neuropathy, paresthesia, tremor, vertigo, depression, insomnia, somnolence, abnormal dreams, reflexes decreased, hypesthesia.

Respiratory: asthma, dyspnea, laryngitis, pharyngitis, sinusitis, bronchitis, sputum increased, cough increased.

Skin and Appendages: urticaria, herpes simplex, pruritus, sweating, skin ulcer, contact dermatitis, exfoliative dermatitis.

Special Senses: mydriasis, conjunctivitis, photophobia, tinnitus, eye pain, deafness, ear pain, eye hemorrhage, cataract, dry eyes.

Urogenital: cystitis, nocturia, urinary frequency, breast enlargement, urinary incontinence, abnormal ejaculation, genital edema and anorgasmia.

POST-MARKETING EXPERIENCE:

Cardiovascular and cerebrovascular

Serious cardiovascular, cerebrovascular, and vascular events, including myocardial infarction, sudden cardiac death, ventricular arrhythmia, cerebrovascular hemorrhage, transient ischemic attack, hypertension, subarachnoid and intracerebral hemorrhages, and pulmonary hemorrhage have been reported post-marketing in temporal association with the use of VIAGRA. Most, but not all, of these patients had preexisting cardiovascular risk factors. Many of these events were reported to occur during or shortly after sexual activity, and a few were reported to occur shortly after the use of VIAGRA without sexual activity. Others were reported to have occurred hours to days after the use of VIAGRA and sexual activity. It is not possible to determine whether these events are related directly to VIAGRA, to sexual activity, to the patient's underlying cardiovascular disease, to a combination of these factors, or to other factors (see WARNINGS for further important cardiovascular information).

Other events

Other events reported post-marketing to have been observed in temporal association with VIAGRA and not listed in the pre-marketing adverse reactions section above include:

Nervous: seizure and anxiety.

Urogenital: prolonged erection, priapism (see WARNINGS) and hematuria.

Special Senses: diplopia, temporary vision loss/decreased vision, ocular redness or bloodshot appearance, ocular burning, ocular swelling/pressure, increased intraocular pressure, retinal vascular disease or bleeding, vitreous detachment/traction, paramacular edema and epistaxis.

Non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, has been reported rarely post-marketing in temporal association with the use of phosphodiesterase type 5 (PDE5) inhibitors, including VIAGRA. Most, but not all, of these patients had underlying anatomic or vascular risk factors for developing NAION, including but not necessarily limited to: low cup to disc ratio ("crowded disc"age over 50, diabetes, hypertension, coronary artery disease, hyperlipidemia and smoking. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors, to the patient's underlying vascular risk factors or anatomical defects, to a combination of these factors, or to other factors (see PRECAUTIONS/Information for Patients).

OVERDOSAGE

In studies with healthy volunteers of single doses up to 800 mg, adverse events were similar to those seen at lower doses but incidence rates were increased.

In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and it is not eliminated in the urine.

DOSAGE AND ADMINISTRATION

For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, VIAGRA may be taken anywhere from 4 hours to 0.5 hour before sexual activity. Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. The maximum recommended dosing frequency is once per day.

The following factors are associated with increased plasma levels of sildenafil: age >65 (40% increase in AUC), hepatic impairment (e.g., cirrhosis, 80%), severe renal impairment (creatinine clearance <30 mL/min, 100%), and concomitant use of potent cytochrome P450 3A4 inhibitors [ketoconazole, itraconazole, erythromycin (182%), saquinavir (210%)]. Since higher plasma levels may increase both the efficacy and incidence of adverse events, a starting dose of 25 mg should be considered in these patients.

Ritonavir greatly increased the systemic level of sildenafil in a study of healthy, non-HIV infected volunteers (11-fold increase in AUC, see Drug Interactions.) Based on these pharmacokinetic data, it is recommended not to exceed a maximum single dose of 25 mg of VIAGRA in a 48 hour period.

VIAGRA was shown to potentiate the hypotensive effects of nitrates and its administration in patients who use nitric oxide donors or nitrates in any form is therefore contraindicated.

Simultaneous administration of VIAGRA doses above 25 mg and an alpha-blocker may lead to symptomatic hypotension in some patients. Doses of 50 mg or 100 mg of VIAGRA should not be taken within 4 hours of alpha-blocker administration. A 25 mg dose of VIAGRA may be taken at any time.

HOW SUPPLIED

VIAGRA® (sildenafil citrate) is supplied as blue, film-coated, rounded-diamond-shaped tablets containing sildenafil citrate equivalent to the nominally indicated amount of sildenafil as follows:

	25 mg	50 mg	100 mg
Obverse	VGR25	VGR50	VGR100
Reverse	PFIZER	PFIZER	PFIZER
Bottle of 30	NDC-0069-4200-30	NDC-0069-4210-30	NDC-0069-4220-30
Bottle of 100	N/A	NDC-0069-4210-66	NDC-0069-4220-66

Recommended Storage: Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

Rx only

© 2005 PFIZER INC

21 Distributed by LAB-0221-4.0 Revised July 2005 Pfizer Labs Division of Pfizer Inc, NY, NY 10017

back to:Psychiatric Medications Pharmacology Homepage

Suggestions for dealing with various aspects of living with and relating to someone who has bipolar disorder or another mental illness.

Supporting Someone with Bipolar - For Family and Friends

Don't criticize
People struggling with any sort of mental illness are very vulnerable, and cannot defend themselves against direct personal attack. Try to be supportive, and keep negative or nagging remarks to an absolute minimum. If there is one single standard to work for in your relationship with a mentally ill person, it is to respect, and protect, their shattered self-esteem.

Don't press, don't fight, don't punish
"With this disease there is no fighting. You may not fight. You just have to take it and take it calmly. And remember to keep your voice down. Also punishment doesn't work with this disease. Now that I have lived with a person with schizophrenia, it makes me very upset when I see mental health workers try to correct their clients' adverse behavior by punishment, because I know it doesn't work." - Joe Talbot, quoted in The Family Face of Schizophrenia by Patricia Backlar

If you want to influence behavior effectively, the best thing to do is ignore negative behavior as much as you can, and praise positive behavior every chance you get
Study after study shows that if you "accentuate the positive" people will want to perform the behaviors that earn them recognition and approval. Many reliable studies indicate that criticism, conflict and emotional pressure are most highly related to relapse.

Learn to recognize and accept the primary symptoms, and the residual symptoms, of a person's brain disorder
Don't try to "jump start" someone in a depression, or "shoot down" a person with mania, or argue with schizophrenic delusions. Help them learn which of their behaviors are caused by their illness. Tell them it's not their fault if they cannot get out of depression, that they are not "terrible" for the things they did when they were manic, etc. This kind of support relieves a lot of guilt and anxiety, even when someone is still in denial.

Don't buy into the stigma all around you

People with mental illness are not "bad," or ill because of some failure of character. Our family member is not willfully trying to disgrace us, frustrate us and embarrass us. Their behavior is not a reflection on our relationship, or our parenting. They are not dedicated to undermining our dignity, or ruining our prestige and standing in the community. They are simply ill. Stigma ia awfully hard for us to bear in mental illness, but we certainly don't have to go along with it!

Lessen your demand for support from your ill relative
People with mental illness become very "self involved" when so much of their identity and self-respect is at stake. They often cannot fulfill normal family roles. We are all well advised to seek additional sources of emotional support for ourselves when there is mental illness in the family. Then our loved ones can be who they are, and they will feel less guilty for letting us down.

Having made these necessary allowances, treat people with mental illness, day-to-day, just like anybody else
Expect the "basics" we all require to get along together, and set the same limits and expectations for reasonable order that would exist if they were well. It is very reassuring to people with mental illness when we make a clear distinction between them as a person, and them as someone who has a problem with disordered behavior. All persons require rules of conduct and cooperative standards to live by.

It is important to encourage independent behavior
Ask your ill family member what they feel they are ready to do. Plan for progress in small steps that have a better chance for success. Make short-term plans and goals and be prepared for changes in directions, and retreats. Progress in mental illness requires flexibility; it means giving up our zeal for progress measured by normal standards. There is lots more danger in pushing than there is in waiting. When they are ready, they move.

It doesn't help us to cling to the past, or dwell on "what might have been"
The best gift we can offer is to accept that mental illness is a fact in the life of someone we love, and look ahead with hope to the future. It is important to tell our family members that mental illness makes life difficult, but not impossible. This is the only way it is now; things can be better. People come out of these illnesses; people get better. Family members can help keep the future alive; most people with mental illness do struggle on and rebuild their lives.

Every time our relatives "get better" and show improvement, for them it means that they are moving back into a risk position
Being well signals that they might be required to participate in the real world, and this is a frightening prospect for the "shaky self." So, it is important for us to be very patient in wellness, just as we are in illness. People recovering from mental illness still have the awesome task of accepting what has happened to them, finding new meaning in life, and constructing a way of living that protects them from becoming ill again.

Empathy must also extend to each of us who struggle to understand and encourage those we love who have mental illness. Remember, we can only try to do our best. We cannot do any better than that. Some illness processes get "stuck" no matter what we do to help. Brain disorders go through hard, intractable periods where helping those who suffer them is often very difficult to do. We can hope, we can assist, we can keep on trying, but we can't produce miracles.

Families tell us that the most important "grace" one learns is the process of caring for people with mental illness is forbearance, synonymous with tolerance, charity, endurance and self-restraint
Do not criticize yourself if you sometimes cannot muster up these graces when you are feeling frightened or frustrated. For all of us, coming to terms with changed life circumstances in serious illness is a huge adjustment. We do know that empathetic understanding will deepen and enrich our relationships with our relative suffering from a mental illness.

next: Help for Surviving Your Spouse's Mental Illness
~ bipolar disorder library
~ all bipolar disorder articles

An innovative new level of Inner Child Healing - a healing paradigm that includes tools, techniques, and perspectives for achieving spiritual integration and emotional balance.

• Feeling the Feelings

• Grief, Love, and Fear of Intimacy

• Grief Process Techniques

• Inner Child Healing Techniques

• Internal Boundaries

• Learning to Love Our Self

• Positive Affirmations

---

continue story below

---

next: Feeling the Feelings

Problems ADHD teens may have with different types of relationships and how to handle them.

ADHD can have a marked effect on relationships in the teenage years - with friends, parents, siblings, other family members and partners.

Impact of ADHD  on Friendships

• Teens with ADHD may feel 'different' from their peers and feel socially isolated.
• Friends' parents may think they're troublemakers.
• They may not notice how friends are feeling, especially if focused on something else.
• They may clash with friends because they speak before they think.

Ways to tackle

• Encourage friendships.
• Let your teen invite people home as often as possible.
• Have a discreet word with the parents of friends. Talk about the problems and encourage them to view your child in a more positive light.
• Teach your teen social skills such as how to read people's body language. This will help him see when he's at odds with friends and why.
• Teach your teen to take a deep breath before he says or does something. Ask him to think about how he'd feel if someone said or did that to him.

ADHD's Effect on Relationship with Parents

• Most teenagers think they're old enough to do something, whereas their parents feel the opposite.
• For teens with ADHD, the situation's even harder because the ADHD means they tend to react as if they're two or three years younger than they are. This means parents find it difficult to give them more freedom.
• There may also be conflict between parents as to the best way to handle the teen.

Ways to tackle

• Work as a partnership - parents and teenager need to be on the same team and respect each other.
• Discuss the issues and work out possible solutions together. This way, you'll end up with a set of house rules that everyone can work with.
• Include consequences of what happens if your teen doesn't stick to the rules, and follow through.
• Expect your teen to be responsible and treat him as if he'll do well. If you expect him to fail or behave badly and treat him as if he's going to go wrong, he probably will.
• Listen to each other and keep communication going.
• Keep calm - if you lose control, you'll lose your authority.

Effect of ADHD  Teen on Siblings and Other Family Members

• Siblings may feel that the child with ADHD gets all the attention and resent them having a different set of rules.
• Teens with ADHD might not respect their siblings' space.
• They may squabble more.
• They may not be able to 'put the brakes on'.
  Their behaviour may cut short family trips.
• Outside your home, other family members may be critical of your ADHD child or refuse to accept the condition exists.

Ways to tackle

• Make non-negotiable rules about siblings' space and property. This includes no disturbing homework, and any damage to belongings is paid for out of pocket money.
• Explain to your other children why there are different rules.
• Separate squabblers to give them time to calm down.
• Try to share time between your children. For example, the child without ADHD gets one parent to see school plays or sporting events.
• Explain the situation to other family members. If they can't accept it, that's their problem.

Impact of ADHD on Personal Relationships

• Teens with ADHD will be more forgetful than ones without ADHD, and may hurt their partner's feelings. They may have shifts in energy and their boyfriend or girlfriend may find it hard to keep up.
• Teenagers with ADHD may find it harder to manage a relationship at times of stress such as exams. Those with poor impulse control may come on too strong.
• First dates can be very tricky - the teen with ADHD may be so excited that he talks too much or find himself unable to follow the conversation. He may also misread social cues.

Ways to tackle

• First dates are never easy, but the following tips may help your teen.
• If talking too much is likely to be a problem, use a signal as a reminder to stop, eg a vibrating mobile phone alarm.
• Think of a couple of questions to ask your date to show interest in them.
• If you're not sure if it's OK to hold hands or kiss, ask first. Let your date set the pace so you don't come on too strong.

In the long-term, if your teen is finding the relationship hard to manage, he should talk to his girlfriend or boyfriend and explain how he feels. They are likely to understand and may even be able to help him through stressful times.

---

 

---

 

If your child is taking an ADHD stimulant medication and you're considering switching to non-stimulant Strattera, here are some things to keep in mind.

Many parents were excited when Strattera was introduced, especially if they didn't like the idea of giving their child a stimulant or if they were not doing well with their ADHD medicine.

There were several things that kept some kids from being switched over right away though. As a new medicine, some people were hesitant to try it in case it caused as many or more side effects as a stimulant. Others didn't like the idea of waiting the two to four weeks that Strattera takes to be effective.

Of course, if your child's current medication, whether it is Adderall XR, Concerta, or Ritalin LA, etc., is controlling his ADHD symptoms and is not causing significant side effects, like a poor appetite, poor weight gain, or insomnia, than you likely still don't want to change.

Summertime Switch

For a child who was doing well at school, making a big change and taking the risk of interfering with that success is another big reason parents stick with their child's regular medicine.

That makes summer a good time to make a switch if you or your pediatrician have been considering it. Over the summer, you will likely have more time to deal with side effects of Strattera, adjust the dosage of Strattera that your child takes, and give it time to work. And you will have plenty of time before school starts back up again to change back to his old ADHD medicine or switch to a different one if it doesn't work.

Switching to Strattera at Other Times

Waiting until summer is not always practical though. If your child is losing a lot of weight, becomes too irritable when taking a stimulant, or if they just don't seem to work, you may want to try Strattera even if it is right in the middle of the school year.

If your child with ADHD is very hyperactive, aggressive, and impulsive, and gets in trouble a lot, the idea of sending him to school without any symptom control likely doesn't sound like a good idea. In situations like this, while waiting for the Strattera to take effect, many doctors also prescribe the child's stimulant medicine to take at the same time for a few weeks. They then later stop the stimulant, continue the Strattera, and see how well it is working.

Making Strattera Work

Many people have been concerned that Strattera doesn't seem to work as well as stimulants do. Part of the reason has been that most Pediatricians were only switching their children who weren't doing well on a stimulant. Expecting these children who weren't easy to treat with a stimulant to all of a sudden do great with just Strattera likely isn't fair.

Many Pediatricians also don't have a lot of experience with Strattera yet, so they may not know to increase the dose if it isn't working, give the dose at night if it is making the child too sleepy, or change to a twice a day dose if it is causing stomachaches.

Parents and teachers also often have unrealistic expectations of a child that goes from a stimulant to Strattera. They may expect the medicine to work right away or to work in exactly the same way as a stimulant. With Strattera, although they may pay attention well and not be easily distracted, it doesn't always seem to control symptoms of hyperactivity as well as a stimulant might.

Why should you accept less symptom control when changing your child's medicine?

Well, you shouldn't if your child was doing well on a stimulant and it wasn't causing side effects. But if your child was not tolerating a stimulant, then you may have to accept the way Strattera works for your child, especially if they are getting their work done at school and aren't getting in trouble.

For many other kids with ADHD, Strattera does seem to offer symptom control that compares to a stimulant. In fact, the American Academy of Child and Adolescent Psychiatry recently introduced new ADHD treatment guidelines that listed Strattera as being a first-line treatment option.

Strattera Suicide Warning

Although infrequent, the FDA has warned about an increased risk of suicidal thinking in children and adolescents being treated with Strattera. Specifically, like many other psychiatric medications, the FDA states that Strattera 'may increase thoughts of suicide or suicide attempts in children and teens,' and that parents should call their child's doctor if their child has:

• new or increased thoughts of suicide
• changes in mood or behavior including becoming irritable or anxious

This warning doesn't mean that your child can't be prescribed Strattera or that he should stop taking Strattera if it is doing a good job managing his ADHD symptoms and not causing side effects. Instead, the benefit of taking Strattera should be weighed against the possible risks of the drug. And children taking Strattera should be 'observed closely for clinical worsening, suicidal thinking or behaviors, or unusual changes in behavior,' especially in the first few months of starting treatment or when the dosage is changed.

---

---

next: Which ADHD Medication is Right for Your Child
~ adhd library articles
~ all add/adhd articles

Assessing The Situation

Once it is suspected that someone has an eating disorder, there are several ways of assessing the situation further, from a personal as well as a professional level. This chapter will review assessment techniques that can be used by loved ones and significant others, in addition to those used in professional settings. Advances in our understanding and treatment for anorexia nervosa and bulimia nervosa have resulted in improvements in assessment tools and techniques for these disorders. Standard assessments for binge eating disorder are still being developed because less is known about the clinical features involved in this disorder. An overall assessment should ultimately include three general areas: behavioral, psychological, and medical. A thorough assessment should provide information on the following: history of body weight, history of dieting, all weight loss - related behaviors, body image perception and dissatisfaction, current and past psychological, family, social, and vocational functioning, and past or present stressors.

ASSESSING THE SITUATION IF YOU ARE A SIGNIFICANT OTHER

If you suspect that a friend, relative, student, or colleague has an eating disorder and you want to help, first you need to gather information in order to substantiate your concerns. You can use the following checklist as a guide.

CHECKLIST OF OBSERVABLE AND NONOBSERVABLE SIGNS OF AN EATING DISORDER

---

• Does anything to avoid hunger and avoids eating even when hungry
• Is terrified about being overweight or gaining weight
• Obsessive and preoccupied with food
• Eats large quantities of food secretly
• Counts calories in all foods eaten
• Disappears into the bathroom after eating
• Vomits and either tries to hide it or is not concerned about it
• Feels guilty after eating
• Is preoccupied with a desire to lose weight
• Must earn food through exercising
• Uses exercise as punishment for overeating
• Is preoccupied with fat in food and on the body
• Increasingly avoids more and more food groups
• Eats only nonfat or "diet" foods
• Becomes a vegetarian (in some cases will not eat beans, cheese, nuts, and other vegetarian protein)
• Displays rigid control around food: in the type, quantity, and timing of food eaten (food may be missing later)
• Complains of being pressured by others to eat more or eat less
• Weighs obsessively and panics without a scale available
• Complains of being too fat even when normal weight or thin, and at times isolates socially because of this
• Always eats when upset
• Goes on and off diets (often gains more weight each time)
• Forgoes nutritious food on a regular basis for sweets or alcohol
• Complains about specific body parts and asks for constant reassurance regarding appearance
• Constantly checks the fitting of belt, ring, and "thin" clothes to see if any fit too tightly
• Checks the circumference of thighs particularly when sitting and space between thighs when standing

---

Is found using substances that could affect or control weight such as:

• Laxatives
• Diuretics
• Diet pills
• Caffeine pills or large amounts of caffeine
• Other amphetamines or stimulants
• Herbs or herbal teas with diuretic, stimulant, or laxative effects
• Enemas
• Ipecac syrup (household item that induces vomiting for poison control)
• Other

If the person you care about displays even a few of the behaviors on the checklist, you have reason to be concerned. After you have assessed the situation and are reasonably sure there is a problem, you will need help deciding what to do next.

ASSESSING THE SITUATION IF YOU ARE A PROFESSIONAL

Assessment is the first important step in the treatment process. After a thorough assessment, a treatment plan can be formulated. Since the treatment for eating disorders takes place on three simultaneous levels, the assessment process must take all three into consideration:

• Physical correction of any medical problem.
• Resolving underlying psychological, family, and social problems.
• Normalizing weight and establishing healthy eating and exercise habits.

There are several avenues the professional can use for assessing an individual with disordered eating, including face-to-face interviews, inventories, detailed history questionnaires, and mental measurement testing. The following is a list of specific topics that should be explored.

ASSESSMENT TOPICS

• Eating behaviors and attitudes
• History of dieting
• Depression
• Cognitions (thought patterns)
• Self-esteem
• Hopelessness and suicidality
• Anxiety
• Interpersonal skills
• Body image, shape, and weight concerns
• Sexual or other trauma
• Perfectionism and obsessive-compulsive behavior
• General personality
• Family history and family symptoms
• Relationship patterns
• Other behaviors (e.g., drug or alcohol abuse)

---

ASSESSMENT STRATEGIES AND GUIDELINES

It is important to get necessary information from clients while at the same time establishing rapport and creating a trusting, supportive environment. If less information is gathered in the first interview because of this, that is acceptable, as long as the information is eventually obtained. It is of primary importance that the client knows that you are there to help and that you understand what she is going through. The following guidelines for gathering information will help:

• Data: Gather the most important identifying data - age, name, phone, address, occupation, spouse, and so on. Presentation: How does the client look, act, and present herself?
• Reason for seeking eating disorder treatment: What is her reason for coming for help? Don't assume that you know. Some bulimics are coming because they want to be better anorexics. Some clients are coming for their depression or relationship problems. Some come because they think you have a magic answer or a magic diet to help them lose weight. Find out from the client's own words!
• Family information: Find out information about the parents and/or any other family members. Find out this information from the client and, if possible, from the family members, too. How do they get along? How do they see the problem? How have they, or do they, attempt to deal with the client and the problem?
• Support systems: Who does the client usually go to for help? From whom does the client get her normal support (not necessarily regarding the eating disorder)? With whom does she feel comfortable sharing things? Who does she feel really cares? It is helpful to have a support system in recovery other than the treating professionals. The support system can be the family or a romantic partner but doesn't have to be. It may turn out that members of a therapy or eating disorders support group and/or a teacher, friend, or coach provide the needed support. I have found that clients with a good support system recover much faster and more thoroughly than those without.
• Personal goals: What are the client's goals regarding recovery? It is important to determine these, as they may be different from those of the clinician. To the client, recovery may mean being able to stay 95 pounds, or gaining 20 pounds because "my parents won't buy me a car unless I weigh 100 pounds." The client may want to learn how to lose more weight without throwing up, even though only weighing 105 at a height of 5'8". You must try to find out the client's true goals, but don't be surprised if she really doesn't have any. It may be that the only reason some clients come for treatment is that they were forced to be there or they are trying to get everyone to stop nagging them. However, usually underneath, all clients want to stop hurting, stop torturing themselves, stop feeling trapped. If they don't have any goals, suggest some - ask them if they wouldn't like to be less obsessed and, even if they want to be thin, wouldn't they also like to be healthy. Even if clients suggest an unrealistic weight, try not to argue with them about it. This does no good and scares them into thinking you are going to try to make them fat. You might respond that the client's weight goal is an unhealthy one or that she would have to be sick to reach or maintain it, but at this point it is important to establish understanding without judgment. It is fine to tell clients the truth but is important that they know the choice for how to deal with that truth is theirs. As an example, when Sheila first came in weighing 85 pounds, she was still on a losing weight pattern. There was no way I could have asked her to start gaining weight for me or for herself; that would have been premature and would have ruined our relationship. So, instead, I got her to agree to remain at 85 pounds and not lose any more weight and to explore with me how much she could eat and still stay that weight. I had to show her, help her to do that. Only after time was I able to gain her trust and alleviate her anxiety in order for her to gain weight. Clients, whether anorexic, bulimic, or binge eaters, don't have any idea what they can eat just to maintain their weight. Later, when they trust the therapist and are feeling safer, another weight goal can be established.

• Chief complaint: You want to know what's wrong from the client's perspective. This will depend on whether they were forced to get treatment, or came in voluntarily, but either way the chief complaint usually changes the safer the client feels with the clinician. Ask the client, "What are you doing with food that you would like to stop doing?" "What can't you do with food that you would like to be able to do?" "What do others want you to do or stop doing?" Ask what physical symptoms the client has and what thoughts or feelings get in her way.
• Interference: Find out how much the disordered eating, body image, or weight control behaviors are interfering with the client's life. For example: Do they skip school because they feel sick or fat? Do they avoid people? Are they spending a lot of money on their habits? Are they having a hard time concentrating? How much time do they spend weighing themselves? How much time do they spend buying food, thinking about food, or cooking food? How much time do they spend exercising, purging, buying laxatives, reading about weight loss, or worrying about their bodies?

---

• Psychiatric history: Has the client ever had any other mental problems or disorders? Have any family members or relatives had any mental disorders? The clinician needs to know if the client has other psychiatric conditions, such as obsessive- compulsive disorder or depression, that would complicate treatment or indicate a different form of treatment (e.g., signs of depression and a family history of depression that might warrant antidepressant medication sooner than later in the course of treatment). Symptoms of depression are common in eating disorders. It is important to explore this and see how persistent or bad the symptoms are. Many times clients are depressed because of the eating disorder and their unsuccessful attempts to deal with it, thus increasing low self-esteem. Clients also get depressed because their relationships often fall apart over the eating disorder. Furthermore, depression can be caused by nutritional inadequacies. However, depression may exist in the family history and in the client before the onset of the eating disorder. Sometimes these details are hard to sort out. The same is often true for other conditions such as obsessive-compulsive disorder. A psychiatrist experienced in eating disorders can provide a thorough psychiatric evaluation and recommendation regarding these issues. It is important to note that antidepressant medication has been shown to be effective in bulimia nervosa even if the individual does not have symptoms of depression.
• Medical history: The clinician (other than a physician) doesn't have to go into great specifics here because one can get all the details from the physician (see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa"). However, it is important to ask questions in this area to get an overall picture and because clients don't always tell their doctors everything. In fact, many individuals do not tell their doctors about their eating disorder. It is valuable to know if the client is often sickly or has some current or past problems that could have affected or have been related to their eating behaviors. For example, ask if the client has regular menstrual cycles, or if she is cold all the time, or constipated. It is also important to distinguish between true anorexia (loss of appetite) and anorexia nervosa. It is important to determine if a person is genetically obese with fairly normal food intake or is a binge eater. It is critical to discover if vomiting is spontaneous and not willed or self-induced. Food refusal can have other meanings than those found in the clinical eating disorders. An eight-year-old was brought in because she had been gagging on food and refusing it and had therefore been diagnosed with anorexia nervosa. During my assessment I discovered she was afraid of gagging due to sexual abuse. She had no fear of weight gain or body image disturbance and had been inappropriately diagnosed.
• Family patterns of health, food, weight, and exercise: This may have a great bearing on the cause of the eating disorder and/or the forces that sustain it. For example, clients with overweight parents who have struggled with their own weight unsuccessfully over the years may provoke their children into early weight loss regimens, causing in them a fierce determination not to follow the same pattern. Eating disorder behaviors may have become the only successful diet plan. Also, if a parent pushes exercise, some children may develop unrealistic expectations of themselves and become compulsive and perfectionistic exercisers. If there is no nutrition or exercise knowledge in the family or there is misinformation, the clinician may be up against unhealthy but long-held family patterns. I'll never forget the time I told the parents of a sixteen-year-old binge eater that she was eating too many hamburgers, french fries, burritos, hot dogs, and malts. She had expressed to me that she wanted to have family meals and not be sent for fast food all the time. Her parents didn't supply anything nutritious in the house, and my client wanted help and wanted me to talk to them. When I approached the subject, the father got upset with me because he owned a fast-food drive-through stand where the whole family worked and ate. It was good enough for him and his wife and it was good enough for his daughter, too. These parents had their daughter working there and eating there all day, providing no other alternative. They had brought her into treatment when she had tried to kill herself because she was "miserable and fat" and they wanted me to "fix" her weight problem.
• Weight, eating, diet history: A physician or dietitian on the team can get detailed information in these areas, but it is important for the therapist to have this information as well. In cases where there is no physician or dietitian, it becomes even more important for the therapist to explore these areas in detail. Get a detailed history of all weight issues and concerns. How often does the client weigh herself? How has the client's weight changed over the years? What was her weight and eating like when she was little? Ask clients what was the most they ever weighed and the least? How did they feel about their weight then? When did they first start feeling bad about their weight? What kind of eater were they? When did they first diet? How did they try to diet? Did they take pills, when, how long, what happened? What different diets have they tried? What are all the ways they tried to lose weight, and why do they think these ways haven't worked? What, if anything, has worked? These questions will reveal healthy or unhealthy weight loss, and they also tell how chronic the problem is. Find out about each client's current dieting practices: What kind of diet are they on? Do they binge, throw up, take laxatives, enemas, diet pills, or diuretics? Are they currently taking any drugs? Find out how much of these things they take and how often. How well do they eat now, and how much do they know about nutrition? What is an example of what they consider a good day of eating and a bad one? I may even give them a mini - Å“nutrition quiz to see how much they really know and to "open their eyes" a little bit if they are misinformed. However, a thorough dietary assessment should be performed by a registered dietitian who specializes in eating disorders.

---

• Substance abuse: Often, these clients, especially bulimics, abuse other substances besides food and diet-related pills or items. Be careful when asking about these matters so clients do not think you are categorizing them or just deciding they are hopeless addicts. They often see no connection between their eating disorders and their use or abuse of alcohol, marijuana, cocaine, and so on. Sometimes they do see a connection; for example, "I snorted coke because it made me lose my appetite. I wouldn't eat so I lost weight, but now I really like the coke all the time and I eat anyway." Clinicians need to know about other substance abuse that will complicate treatment and may give further clues into the client's personality (e.g., that they are a more addictive personality type or the type of person who needs some form of escape or relaxation, or they are destructive to themselves for an unconscious or subconscious reason, and so on).

• Any other physical or mental symptoms: Make sure you explore this area fully, not just as it pertains to the eating disorder. For example, eating disorder clients often suffer from insomnia. They often do not connect this to their eating disorders and neglect to mention it. To varying degrees, insomnia has an effect on the eating disorder behavior. Another example is that some anorexics, when questioned often report a history of past obsessive-compulsive behavior such as having to have their clothes in the closet arranged perfectly and according to colors or they had to have their socks on a certain way every day, or they may pull out leg hairs one by one. Clients may not have any idea that these types of behaviors are important to divulge or will shed any light on their eating disorder. Any physical or mental symptom is important to know. Keep in your mind, and let the client know as well, that you are treating the whole person and not just the eating disorder behaviors.
• Sexual or physical abuse or neglect: Clients need to be asked for specific information about their sexual history and about any kind of abuse or neglect. You will need to ask specific questions about the ways they were disciplined as children; you will need to ask if they were ever hit to a degree that left marks or bruises. Questions about being left alone or being fed properly are also important, as is information such as their age the first time they had intercourse, whether their first intercourse was consensual, and if they were touched inappropriately or in a way that made them uncomfortable. Clients often do not feel comfortable revealing this kind of information, especially at the beginning of treatment, so it is important to ask if the client felt safe as a child, who the client felt safe with, and why. Come back to these questions and issues after treatment has been under way for a while and the client has developed more trust.
• Insight: How aware is the client about her problem? How deeply does the client understand what is going on both symptomatically and psychologically? How aware is she of needing help and of being out of control? Does the client have any understanding of the underlying causes of her disorder?
• Motivation: How motivated and/or committed is the client to get treatment and to get well?

These are all things that the clinician needs to assess during the early stages of eating disorders treatment. It may take a few sessions or even longer to get information in each of these areas. In some sense, assessment actually continues to take place throughout therapy. It may actually take months of therapy for a client to divulge certain information and for the clinician to get a clear picture of all the issues outlined above and to sort them out as they relate to the eating disorder. Assessment and treatment are ongoing processes tied together.

STANDARDIZED TESTS

A variety of questionnaires for mental measurement have been devised to help professionals assess behaviors and underlying issues commonly involved in eating disorders. A brief review of a few of these assessments follows.

---

EAT (EATING ATTITUDES TEST)

One assessment tool is the Eating Attitudes Test (EAT). EAT is a rating scale that is designed to distinguish patients with anorexia nervosa from weight-preoccupied, but otherwise healthy, female college students, which these days is a formidable task. The twenty-six item questionnaire is broken down into three subscales: dieting, bulimia and food preoccupation, and oral control.

The EAT can be useful in measuring pathology in underweight girls but caution is required when interpreting the EAT results of average weight or overweight girls. The EAT also shows a high false-positive rate in distinguishing eating disorders from disturbed eating behaviors in college women. The EAT has a child version, which researchers have already used to gather data. It has shown that almost 7 percent of eight- to thirteen-year-old children score in the anorexic category, a percentage that closely matches that found among adolescents and young adults.

There are advantages to the self-report format of the EAT, but there are also limitations. Subjects, particularly those with anorexia nervosa, are not always honest or accurate when self-reporting. However, the EAT has been shown to be useful in detecting cases of anorexia nervosa, and the assessor can use whatever information is gained from this assessment combined with other assessment procedures to make a diagnosis.

EDI (EATING DISORDER INVENTORY)

The most popular and influential of the available assessment tools is the Eating Disorder Inventory, or EDI, developed by David Garner and colleagues. The EDI is a self-report measure of symptoms. Although the intent of the EDI was originally more limited, it is being used to assess the thinking patterns and behavioral characteristics of anorexia nervosa and bulimia nervosa. The EDI is easy to administer and provides standardized subscale scores on several dimensions that are clinically relevant to eating disorders. Originally there were eight subscales. Three of the subscales assess attitudes and behaviors concerning eating, weight, and shape. These are drive for thinness, bulimia, and body dissatisfaction. Five of the scales measure more general psychological traits relevant to eating disorders. These are ineffectiveness, perfectionism, interpersonal distrust, awareness of internal stimuli, and maturity fears. The EDI 2 is a follow-up to the original EDI and includes three new subscales: asceticism, impulse control, and social insecurity.

The EDI can provide information to clinicians that is helpful in understanding the unique experience of each patient and in guiding treatment planning. The easy-to-interpret graphed profiles can be compared to norms and to other eating disordered patients and can be used to track progress of the patient during the course of treatment. The EAT and the EDI were developed to assess the female population who most likely have or are susceptible to developing an eating disorder. However, both of these assessment tools have been used with males with eating problems or compulsive exercise behaviors.

In nonclinical settings the EDI provides a means of identifying individuals who have eating problems or those at risk for developing eating disorders. The body dissatisfaction scale has been successfully used to predict the emergence of eating disorders in high-risk populations.

There is a twenty-eight-item, multiple-choice, self-report measure for bulimia nervosa known as BULIT-R that was based on the DSM III-R criteria for bulimia nervosa and is a mental measurement tool to assess the severity of this disorder.

BODY IMAGE ASSESSMENTS

Body image disturbance has been found to be a dominant characteristic of eating disordered individuals, a significant predictor of who might develop an eating disorder and an indicator of those individuals having received or still receiving treatment who might relapse. As Hilda Bruch, a pioneer in eating disorder research and treatment, pointed out, "Body image disturbance distinguishes the eating disorders, anorexia nervosa and bulimia nervosa, from other psychological conditions that involve weight loss and eating abnormalities and its reversal is essential to recovery." This being true, it is important to assess body image disturbance in those with disordered eating. One way to measure body image disturbance is the Body Dissatisfaction subscale of the EDI mentioned above. Another assessment method is the PBIS, Perceived Body Image Scale, developed at British Columbia's Children's Hospital.

The PBIS provides an evaluation of body image dissatisfaction and distortion in eating disordered patients. The PBIS is a visual rating scale consisting of eleven cards containing figure drawings of bodies ranging from emaciated to obese. Subjects are given the cards and asked four different questions that represent different aspects of body image. Subjects are asked to pick which of the figure cards best represents their answers to the following four questions:

• Which body best represents the way you think you look?
• Which body best represents the way you feel you are?
• Which body best represents the way you see yourself in the mirror?
• Which body best represents the way you would like to look?

---

The PBIS was developed for easy and rapid administration to determine which components of body image are disturbed and to what degree. The PBIS is useful not only as an assessment tool but also as an interactive experience facilitating the therapy.

There are other assessment tools available. In assessing body image it is important to keep in mind that body image is a multifaceted phenomenon with three main components: perception, attitude, and behavior. Each of these components needs to be considered.

Other assessments can be done to gather information in the various domains, such as the "Beck Depression Inventory" to assess depression, or assessments designed specifically for dissociation or obsessive-compulsive behavior. A thorough psychosocial evaluation should be done to gather information on family, job, work, relationships, and any trauma or abuse history. Additionally, other professionals can perform assessments as part of a treatment team approach. A dietitian can do a nutrition assessment and a psychiatrist can perform a psychiatric evaluation. Integrating the results of various assessments allows the clinician, patient, and treatment team to develop an appropriate, individualized treatment plan. One of the most important assessments of all that needs to be obtained and maintained is the one performed by a medical doctor to evaluate the individual's medical status.

MEDICAL ASSESSMENT

The information on the following pages is an overall summary of what is needed in a medical assessment. For a more detailed and thorough discussion of medical assessment and treatment, see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa."

Eating disorders are often referred to as psychosomatic disorders, not because the physical symptoms associated with them are "all in the person's head," but because they are illnesses where a disturbed psyche directly contributes to a disturbed soma (body). Aside from the social stigma and psychological turmoil that an eating disorder causes in an individual's life, the medical complications are numerous, ranging all the way from dry skin to cardiac arrest. In fact, anorexia nervosa and bulimia nervosa are two of the most life-threatening of all psychiatric illnesses. The following is a summary of the various sources from which complications arise.

SOURCES OF MEDICAL SYMPTOMS IN PATIENTS WITH EATING DISORDERS

• Self-starvation
• Self-induced vomiting
• Laxative abuse
• Diuretic abuse
• Ipecac abuse
• Compulsive exercise
• Binge eating
• Exacerbation of preexisting diseases (e.g., insulin-dependent diabetes mellitus)
• Treatment effects of nutritional rehabilitation and psychopharmacological agents (drugs prescribed to alter mental functioning)

A THOROUGH MEDICAL ASSESSMENT INCLUDES

• A physical exam
• Laboratory and other diagnostic tests
• A nutritional assessment/evaluation
• A written or oral interview of weight, dieting, and eating behavior
• Continued monitoring by a physician. The physician must treat any medical or biochemical cause for the eating disorder, treat the medical symptoms that arise as a result of the eating disorder, and must rule out any other possible explanations for symptoms such as malabsorption states, primary thyroid disease, or severe depression resulting in loss of appetite. Additionally, medical complications may arise as consequences of the treatment itself; for example, refeeding edema (swelling that results from the starved body's reaction to eating again - see chapter 15) or complications from mind-altering medications prescribed
• Assessment and treatment of any needed psychotropic medication (most often referred to a psychiatrist)

A normal lab report is not a guarantee of good health, and physicians need to explain this to their patients. In some cases at the discretion of the physician, more invasive tests like an MRI for brain atrophy or bone marrow test may have to be performed to show abnormality. If lab tests are even slightly abnormal, the physician should discuss these with the eating disordered patient and show concern. Physicians are unaccustomed to discussing abnormal lab values unless they are extremely out of range, but with eating disorder patients this may be a very useful treatment tool.

Once it is determined or likely that an individual has a problem that needs attention, it is important to get help not only for the person with the disorder but for those significant others who are also affected. Significant others not only need assistance in understanding eating disorders and in getting their loved ones help but in getting help for themselves as well.

Those who have tried to help know all too well how easy it is to say the wrong thing, feel like they are getting nowhere, lose patience and hope, and become increasingly frustrated, angry, and depressed themselves. For these reasons and more, the following chapter offers guidelines for family members and significant others of individuals with eating disorders

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

next: Eating Disorders Require Medical Attention
~ eating disorders library
~ all articles on eating disorders

In this editorial, Dr. Billy Levin denounces corporal punishment and says children who misbehave need help, not punishment; especially children with ADHD.

Corporal punishment is degrading, embarrassing, painful, abusive and harmful to children and has no benefits other than relieving frustration in an inadequate and ignorant adult bullying perpetrator.

"Science does not prove that G..D is right. G..D proves that science is right". ("Genesis and the Big Bang" by Gerald Schroeder, a pious Jew with a double doctorate in science.) As a very religious person, he has no difficulty writing a book to resolve the age old conflict between science and religion. In fact, he states there is no conflict!

Whenever man has accepted the wisdom of G..D humbly and unconditionally because of his faith in a "higher being", man has never been disappointed nor let down. Eventually, sooner or later, science has proved the custom or law to be correct and valuable in every aspect. These are a few examples:-

In the Jewish faith, one is not allowed to have milk for a set period of time after having eaten meat. Milk reduces the effect of the gastric juices in digesting meat. There are also laws governing when and how and what meat may be eaten, that were known from Biblical times. Today these laws would be seen as very scientific and medically correct.

Jewish woman, who follow the faith strictly, will attend a communal bath (the Mikva) after their menstrual period has ceased. There is also a requirement not to have sex until the 14th day after the start of the menstrual period. This coincides with ovulation time thus insuring maximum fertility for conception. I am very certain the ancients did not know about the Physiology of conception. Devine intervention?

Bathing in (washing) running water as a means of reducing the spread of infection was practiced in Mose's times, yet surgeons only recognised this as a means of reducing infection at the end of the 18th century.

The age of bar mitzvah for a Jewish boy is 13. The bat mitzva for a girl is at 12 years of age. Girls are more mature. It is recognised that at approximately this age there is a distinct maturing from a cognitive point of view that would make the person more responsible for his actions. The very word "Bar mitzvah" has this very significant meaning.

Once again in the Jewish faith, the ritual circumcision (Brit Mila), is done 8 days after birth. Circumcision done at this age results in a dramatic reduction in cancer of cervix in that person's future wife. But even more significant, is the fact that Prothrombin and Vitamin K, both needed for clotting of blood the prevent serious haemorrhage and so discourage infection is at an optimum at 8 days after birth. Moreover the baby has all his maternal antibodies to assist him to overcome any infection that might result from this circumcision. At a later stage in his life his mother's antibodies that he still has in his own circulation as an infant(8 days old) would decrease to nearly zero. The child would not have had enough time to have been exposed to the various germs and developed his own antibodies yet. Thus there would be a greater risk of infection if the circumcision was done at a later stage. Who new of Vitamin K and Prothrombin in those days. Clearly Devine intervention.

All these are examples of strict ancient religious requirements having a very good scientific explanation when viewed with our modern knowledge of today.

Therefore, if science proves corporal punishment is harmful for children, G..D must have known about this harm long before man researched it. Therefore "PROVERBS 13, 24 (spare the rod and spoil the child), written by King Solomon must have been interpreted by man incorrectly. The learned sages warn that some of King Solomon's writings are notorious for being misunderstood. The bible is always right, man may make mistakes. Unless of course, science is incorrect!

Proverbs are attributed to King Solomon who was renown for his wisdom. He was a very aggressive and violent king, although many would use the words "harsh" and "strict". If he used the rod on his children it certainly bred much aggression in his son, ........ who succeeded him. Solomon's son on his succession to the thrown is quoted as saying "If my father lashed the people with lashes, I will lash them with scorpions" Aggression breeds aggression. History tells us that this King brought about the downfall of the Hebrew kingdom and the splitting of the nation with his ruthless rule. The people were eventually forced to rebel against his tyranny. What Solomon had built up he broke down. His aggression and harsh rule brought ruination . Therefore the wisdom of Solomon is instantly challenged, or perhaps more correctly the interpretation of his writings. In the case of the two mothers fighting about whose baby it was, did Solomon have the wisdom to know the real mother would not want her child divided in half, or was it Solomon's callous disregard for life, to get rid of two nagging women. If it was a callous suggestion, then it was G..D's wisdom that saved the child and Solomon saw the wisdom of G..D. Solomon, after all strayed from the Lord by praying to idols with his many heathen wives. He also married out of the faith which should be questioned. That he was harsh and cruel is well documented. It was this harsh, cruel and straying King who wrote the proverbs including Proverbs 13,24. Because of his tendency to use aggression during his rule, he might well have also used hash aggression and punishment on his own children and produced an even harsher and crueller ruler to follow him, who ruined the nation and provoked then into rebellion. Was this not the same situation with apartheid in South Africa resulting in the overthrowing of the government's tyranny, but the legacy of aggression lingers on. Corporal punishment in schools would certainly breed aggression long after it was banned in schools.

On the Festival of the Passover, it is obligatory to retell the story of the exodus of the Israelites from Egypt to your children every year lest they forget. To the traditional "four sons", each with a different capacity for learning ranging from good to possibly very poor, there is not mention of corporal punishment even for the one who cannot learn. Only repetition.

---

---

---

During the hard times in the Sinai desert, when there was a shortage of water the Israelites complained to Moses, who asked G..d for help. Help was forth coming via the famous Rock. In frustration and desperation Moses is alleged to have struck the "Rock" with his cane instead of speaking to it as instructed by G..d.. Who can blame him? On a previous occasion,( 40 years previously,) just after the crossing of the Red sea, Moses was instructed to strike the rock to provide water. If one considers the Israelites would be more impressed with the striking of the rock as they were used to physical force and punishment as slaves for 400 years. But 40 years later they were learning to be a free people with no need to have aggression shown to them or used to teach their children. Hence the change in modis operandi. "Talk to the rock!" Yet there was a severe punishment metered out by G..d. to Moses for having struck the rock. Moses would never enter the land of Canaan. How much more should the punishment be if innocent children and even perhaps sometimes not so innocent children are struck with a cane? Do parents and teachers get punished for hurting children? Yes, instead of the pleasure and pride of well-adjusted children, they have to grieve and suffer aggravation for their misdirected efforts. If G..d does not want the cane to be used even on an inanimate object like a rock, how much more so in the case of children. The important question is am I interpreting the situation correctly? But in Psalm 23, King David says " Thy rod and Thy staff shall comfort me". This does not sound like a weapon of destruction. G..d's rod and staff is certainly not intended to inflict pain, and neither should ours. It is for our comfort, guidance and protection.

Misinterpreting the Bible Regarding Corporal Punishment

Has man misinterpreted the bible before? The answer is emphatically, yes, on occasion but not always. Man with his limited knowledge and lack of insight has misinterpreted the bible before, on occasions. Like the broken telephone game played by children each interpretation could be even further from the original intended truth. Man is fallible. However the Torah (given at Sinai) and rewritten in exactly the same way and wording by expert scribes over more than three thousands years, has not changed. ( to an accuracy of 99.9% ) This in itself is considered a miracle. With the discovery of the Dead Sea scrolls in the 20th century, untouched for two thousands years, it was possible to compare them with a modern recently written scroll to prove this point. How correctly has man understood and interpreted the book of Genesis and the story of the Creation? Here are a few examples of possible misinterpretation:-

The interpretation of the Hebrew words "Vayehi Orr ", is "And there was light" ( Genesis ) The planet was cooling down from an astronomical "black hole", that did not even allow particles as small as a photon to escape it's gravitational force, to a molten fiery planet that glowed with light.. "And there was light". G..D did not create light, it was there. In Genesis we read about the creations .The sun was only placed in the heavens as a sign of the time on the fourth day(Genesis ). G..d knew we would use the sun's path as a calendar even then already.(Genesis ) So we may conclude the light referred to here was not from the sun, but a glowing planet busy cooling down to allow man to inhabit it many millions of years later.

In the Bible we read about the cherubs that were placed on the sides of the Tabernacle ( Exodus) . Just so we should read that Eve was placed at the side of Adam.(Genesis ), and not created from his side. She was intended to be a life long partner. In Yiddish, a Jewish dialect of the German language, one would say "she walked from his side", meaning she walked at his side. " At the side"' referring to the cherubs was the same wording that referred to Eve at Adam's side. "At the side" not from his side. If Eve was created from Adams side (ribs), she would have the "x' any "y' chromosomes that men have. She only has the "x" chromosome that woman have. At the end of each day of creation there is a statement made :- "And there was evening and there was morning"( Genesis ). This statement is made from the start of creation. On the third day of creation the sun was placed in the heavens. Thus the phrase, "and there was evening and there was morning" could not have referred to our understanding of morning and evening. It certainly could have implied that before creation there was chaos and disorganisation. After the specific creation was completed, there was order and organisation. The ancient Hebrew wording for chaos suggests "darkness", and when someone sheds some light on the chaos there was, not morning, but order.

At the start of creation G..d commenced his miracles on a certain day when the world was ready . The Hebrew words "Yom echad", meaning "On a day (on a certain day) (Genesis ) are used to signify the commencement of creation. .It did not mean "On day one", which would be in Hebrew "Yom Rishon". The creation was not intended to convey a message that it took only one day, but rather on a certain day G..d started creation.

An "eye for an eye and a tooth for a tooth"( Leviticus ) certainly does not mean we should poke out a criminal's eyes or punch out his teeth in violent and aggressive retaliation. It is intended to convey the message that the punishment should fit the crime, measure for measure when compensation is considered.

We should not misinterpret the word "Rod" or "staff' (cane). A shepherds crook is used to guide sheep, not hurt them. The "flock " was often used to indicate, the people, who should be led, not beaten with a shepherd's crook. To use a "crook' to guide your children somehow does not seem correct. The word "crook' has sinister connotations. A rod or staff is more acceptable. The rod is meant to guide and not inflict pain upon innocent children. A pastoral staff forms part of the regalia in certain churches. Once again the reference to leading the Pastor's flock with a guiding staff, and not inflicting pain. The reference is to a staff in the media of the then spoken word. I am not sure when the word "crook" came into the English language, but it was certainly not used in biblical times. A crooked staff with a bend in it was used to catch the sheep's legs, not to choke it by the neck.

Understanding Effective Discipline of Children

Children were not intended to be beaten in submission or bullied into retaliative aggression but rather to be guided gently as with a Shepard's crook. Children with a neurological dysfunction (Attentional Deficit Hyperactivity Disorder) do not yield to this type of discipline and even to aggressive beatings. They require sympathetic medical, educational and sometimes psychological help. These dysfunctional children form the vast majority of severe behaviour problems encountered among children and they are largely misunderstood, neglected and abused by ignorant well meaning ,and sometimes not so well meaning adults and teachers. Children who do not have a neurological dysfunctions may some times stray off the beaten track but they are self correcting with a minimum of guidance. These children respond very well to discipline. They do not need punishment. Discipline and punishment are totally different situations and should not be confused with each other. They are totally different.

---

---

---

Discipline is the loving way of TEACHING children, at the right time, in the right way, at the right place and at the right age. It should be used frequently and repeatedly and lovingly."

"Punishment is the unpleasant task of having to UNREWARD a child for having done wrong despite adequate discipline. It should be used seldom, sparingly, forgivingly and judiciously."

Corporal punishment is never an option! Both these definitions, which I formulated about 20 years ago, assume the child does not have a neurological dysfunction such as Attentional Deficit Hyperactivity Disorder (ADHD). In this case the medical treatment is of paramount importance and a first priority to make the child more teachable. "You cannot teach a child if you cannot reach him. You cannot reach the child if he cannot concentrate and pay attention. He cannot concentrate without the benefit of stimulant medication if he has ADHD. Here medication is not the be-all or end-all, but rather the first step onto a long ladder that the team (parents, teacher, child etc.) has to climb to succeed.

As far back As 1985, Professor Holdstoch wrote a book entitled "BEAT THE CANE". He was professor of Psychology at the University of the Witwatersrand and founded a parent support group called "Education without fear." This was a case for the abolition of corporal punishment in schools in South Africa. In America, England and most of Europe this had already been achieved, in some countries in the previous century! Ten years later Professor Kiebel (professor of paediatrics) wrote in the South African Medical Journal( February 1995) about his disgust that corporal punishment still existed in schools. He was criticised in the journal by colleagues(July 1995) When I supported his opinion with a letter to the same journal (October 1995), there was a stony silence from his critics. It still took a few years after this, for corporal punishment to be banned in South Africa schools. Some religious (pious?) organisations even went to court to have the law banned! South Africa was one of the last of the so called first world countries to prevent hurting children officially in schools.

As clear as the evidence suggests that corporal punishment is detrimental (and not with standing the law banning corporal punishment in schools a T. V. program recently, "The Big Question" took a studio and viewing audience vote on the matter, agreeing it was acceptable to hit children. Did the presenters or the audience know they were voting in favour of an illegal, dangerous and banned practice. Ignorance is not bliss. It is dangerous. These dangers were well demonstrated in the media, about the many violent and aggressive practices in cultural initiation schools for blacks resulting in tragic deaths of young children from beatings in July 2002.

It would be fitting to conclude with the phrase "Ye who amongst us, who is without sin, should cast the first stone". I would also like to include to those who doubt what I have suggested, "Seek and ye shall find". Both these very wise comments are attributed to Jesus of Nazareth. Solomon was quoted as having said "a wise man has his eyes in his head." I cannot remember where the eyes were in a fool! He is also quoted as having said "it is far better to be chastised by a wise man than to listen to the song of a fool!" (Ecclesiastes)

Some years ago, when a Professor Garry Meyers and I both spoke at an international symposium on ADHD, he related a story of the state of Alabama instituting a law that a misbehaving child could only be punished twice. Thereafter, an automatic referral for a Neurological evaluation. Misbehaving children need help not punishment. There should be no confusion between discipline and punishment. Children are "people" too.

About the author: Dr. Levin is a pedaetrician with nearly 30 years of experience and specializes in working with ADHD children. He has published many articles on the subject and is our "ask-the-expert."

---

---

next: Natural Alternatives: Defend-OL, Developmental Integration Technique
~ back to adders.org homepage
~ adhd library articles
~ all add/adhd articles

It can be physically and emotionally tiring raising a child with bipolar disorder. Here are some tips for parenting your bipolar child.

Parenting Tips:

• Make videos of your child's rages and/or psychotic symptoms to show mental health professionals when trying to get a diagnosis. Family members that see the rages might be more likely to believe you also.
• Join a local or online support group. It helps tremendously to speak to other parents dealing with the same issues.
• When you notice your child is hyper or possibly getting manic, try to isolate them from strong sources of stimulation. Closing the curtains, turning off the television, and speaking quietly all help my son calm down.
• Document everything! Tapes, medical records, letters from psychiatrists and doctors, old behavior charts, tests, and school evaluations can come in handy. Keep copies to show the police, the school, and the hospital if needed.
• Watch your child's sleep closely. Too much sleep can signal depression, and too little sleep can even CAUSE mania. Regulating sleep can be very helpful as a treatment too.
• Get an IEP and demand the school follows it. Do not ever forget that an IEP is there to help your child. Legally the school is required to follow it exactly. You are in control, not the teachers.
• Do not neglect yourself or your other children. Parenting a bipolar child can be isolating and stressful. You need to remember to take time off in any way you can.
• Exercise can be an easy and healthy way to burn off manic energy or focus rage. When your child starts showing signs of rage or mania, take her jogging or bike riding.
• If you are having trouble finding a psychiatrist that treats childhood bipolar, try a university or research hospital. Even if no one there can help your child, they almost always have the name of someone who can.
• Try to get your child into therapy. Medications help, but therapy teaches your child how to recognize warning signs of the illness and cope with their emotions.
• If you can't find anyone willing to sit with your child while you go out, find another bp parent and alternate nights out.
• Read everything you can about bipolar, and pass that information on to as many people as possible. Ignorance is our worst enemy.
• Be an advocate for your child at school. Insist your child has all the resources needed to get the best education possible. Educate the teachers and the faculty about your child's needs, and also make certain to point out your child's abilities as well as disabilities.
• Give your child certain chores according to their abilities so that they can be a helpful part of the family and be sure to thank them for their work. Family and child seeing what was accomplished is very important.
• Watch for low self-esteem issues. One parent reports her daughter was so lovely and outgoing and had so many friends that she had no idea that her daughter's self-esteem was so low, causing her great pain and hurt.

See Also:

Parenting Tips for When Your Tween Has a Meltdown

Details social services programs available to disabled children and their parents in the UK.

PLEASE BE AWARE THAT THE INFORMATION BELOW IS GENERAL AND PERTAINS TO THE UK. IT MUST BE REMEMBERED THAT ADD/ADHD IS NOT ALWAYS OFFICIALLY RECOGNISED AS A DISABLITY.

Many children have special needs and disabilities, and some are more severely affected than others. Many disabled children and their parents will need practical support at home. This factsheet explains your right to get the support you need.

Social Services Departments of Local Authorities are responsible for arranging support for children and their carers. You have a right to have your child's and family's needs assessed by Social Services.

Duties of Social Services to disabled children and their families

Duties include:

• providing a social worker service
• maintaining a register of disabled children
• providing information about services which may be available
• assessing the needs of disabled children and their carers
• providing a range of services to meet these needs Social Services Departments have a general duty under Section 17 (10) of the Children Act 1989, to safeguard and promote the interests of children in need. The law recognises disabled children as being in need.

A child in need is entitled to an assessment from the Social Services Department. This assessment will set out the services that are considered necessary. An assessment is important because it can lead to a number of services being provided such as practical help in the home and respite care/short term breaks.

Assessments

How do I request an Assessment of my child's needs?

Many Social Services Departments have Children with Disabilities Teams. You should find the number in the telephone Directory under the name of your local authority or Social Services or ring our freephone helpline 0808 808 3555 for information. Alternatively, you can ask your GP, Health Visitor, Community Nurse or Paediatrician to contact Social Services on your behalf. It is usually a good idea to put your request for an assessment in writing and to keep a copy of your letter. The request does not need to be detailed but at the least should include:

• Your name and address
• Details of who is in your household, including any other children.
• A brief description of your child's disability
• What kind of extra help your child needs
• Whether you need help urgently

What if an Assessment has been carried out in the past?

When services are already being provided the assessment should be reviewed regularly. However, if your circumstances have changed, you can ask for a re-assessment or review in the same way as above.

What if Social Services refuse to carry out an Assessment?

If your child is disabled and in need of services, you cannot legally be refused an assessment. Also, if you need help urgently, you can ask for services to be put in place straight away without waiting for the outcome of an assessment.

What is a Social Services Assessment?

An initial assessment may be carried out to help social services determine whether or not a core assessment (an in-depth assessment) should be carried out. Timescales given to Social workers indicate that the initial assessment should be completed within a maximum of seven working days and the core assessment should not take longer than 35 working days.

Beforehand, you should be told how the assessment will be carried out and be given information about what services are available, not just those which are provided by Social Services Departments (for example, a local play scheme).

It is very important to remember that your child should not be assessed for specific services which are already being provided. Instead the assessment should identify all of your child's needs regardless of whether or not services exist to meet them.

Social Services should assess your child in an open way and the assessment should focus on the circumstances of both your child and the rest of the family. As well as your child's disability and health needs, Social Services should also consider other aspects of your child's life, for example, educational needs and religious or cultural needs.

---

---

---

The Social Worker will usually come to your home to talk to you. They should ask you for information about your child, for example, about sleeping patterns, eating habits, how your child communicates, what activities they enjoy and whether or not you have any other children to look after. Do not be worried about asking for clear information about the focus of the assessment and about what services are available.

Remember however that the assessment should be needs led and not based on services already available.

Make a list of questions if you think that will help and you are entitled to have a friend or advocate there with you. The Social Worker may also want to speak to your child's health visitor, doctor or school to help them get a full picture of his or her needs.

Combining Assessments

The Children Act also says that various assessments can be combined, for example an assessment under the Education Act 1996 or the Chronically Sick and Disabled Persons Act 1970. This means that if your child's Special Educational Needs (SEN) are being assessed for example, then Social Services should assess your child's needs under the Children Act at the same time.

Carer's Assessments

The Carers and Disabled Children Act 2000, which came into force in April 2001, means that parents can request a Carer's Assessment at any time. The Carer's Assessment specifically focuses on you as a parent and your needs.

Social Services should discuss with you various issues such as the help your child needs and whether there is anyone else who helps, or if you are providing all your child's care. The assessment should also consider your well-being, including health and safety issues, and important commitments such as relationships and employment. The aim of an assessment is to give you a chance to tell Social Services about the things that could make looking after your child easier for you.

After the assessment

After Social Services have carried out an Assessment and made a decision as to whether your child is 'in need', they will consider which services your child needs.

Social services may decide that there is no need for services which could result in your case being closed and Social Services taking no further action (if you disagree with the decision you can challenge this using the Local Authorities complaints procedure - further advice about making a complaint can be found later on in this factsheet). Or they may decide that there is a need for services and they should be provided.

What social services can I expect for my disabled child and family?

Services for disabled children are available under Section 2 of the Chronically Sick and Disabled Persons Act 1970 and under the Children Act 1989.

The Chronically Sick and Disabled Person Act sets out what kind of help should be provided. Under this Act, the duty to provide services is to the individual disabled child and does not extend to other members of the family.

The services detailed are:

• practical assistance in the home, such as help with the personal care of your child, e.g. help with getting in and out of bed
• provision of equipment to satisfy a recreational need, such as a TV, radio or computer
• provision of leisure facilities (this could mean outings or a placement at a day centre) or educational facilities (this could mean home-based education or even funding of personal care requirements of students so that they can study)
• travel and other assistance such as travel to and from a day centre
• home adaptations/disabled facilities such as fitting of handrails, hoists etc.
• holidays
• meals
• telephone equipment

The Children Act 1989 sets out a range of support services which should be available. This includes the right to residential accommodation, whether permanent or temporary, where your child needs it. This forms the legal basis for residential respite care. If your child needs this service, then it should be provided. If there are no suitable facilities locally, your Local Authority can look outside its own area. There are other services listed in the Children Act.

Here are some examples:

• occupational, social, cultural or recreational activities
• home help
• assistance to enable your child and family to have a holiday
• advice, guidance or counselling
• travel assistance

---

---

---

Under The Children Act 1989 Local Authorities have a general duty to make a range of services available to help children in the area.

Importantly, The Children Act 1989 allows Social Services to provide help which will benefit other family members, such as siblings and other carers.

When should services be provided?

Services available under both these Acts should be provided when there is an assessed need and services are necessary to meet those needs. In practice, most Local Authorities use 'eligibility criteria' to help them make this decision.

Eligibility criteria

There are many disabled children in an area who need help but Social Services have limited financial resources. Using 'eligibility criteria' for deciding who has a 'need' for services is a way in which they can prioritise to make sure that the people most in need get help. The criteria differ from one authority to another and this means if you move to a different Local Authority area you may no longer qualify for the same help. For example, one of the services listed under the Chronically Sick and Disabled Person's Act is 'holidays'. This does not mean that every disabled child must be given a holiday each time they ask. There will be local eligibility criteria. It might say for instance, that holidays will normally only be given if a child has not had a holiday for 5 years and there is a risk of family breakdown if a holiday is not given.

Once your child's assessed needs match the set local eligibility criteria, the Local Authority has a duty to provide or arrange services to meet those needs. If your child had not had a holiday for 5 years and you could show that your family was under such stress that family breakdown was possible, there would be an obligation to fund the holiday regardless of the Local Authority's financial difficulties. However, the Local Authority can then take its resources into account in deciding how it will actually meet the needs. It might limit the type of holiday it provides, or it might arrange for another organisation to do so. It could even try to apply for a charitable grant to fund the holiday.

If the service is not actually assessed as a need (perhaps seen as only useful), or if it is assessed as a need but does not fit the local criteria, the Local Authority has no actual obligation to provide or arrange provision of the service. The Local Authority should still use its best endeavours to meet the need for example, by contacting a local charity or other voluntary agency to help.

If the decision is that services are not needed, or that you do not fit the eligibility criteria, you should be given clear reasons. This is to help in case you want to challenge the decision using the complaints procedures.

Beware!

It is quite common to hear statements such as 'Our Local Authority no longer provides respite care' or 'We don't do carers assessments in this Local Authority.' These statements are unlawful and you should have good grounds for a complaint (see later). In fact, the Local Authority should not put a blanket ban on any service and should always consider the needs of the individual child and the family. Other families have challenged such statements in court and the courts have decided that a Local Authority cannot 'unlawfully fetter its discretion.' This means that a Local Authority must always be prepared to consider requests which do not fit within its eligibility criteria.

Using the holiday example from earlier, it would be illegal for a Local Authority to say 'we never give holidays to children unless they have not had one for five years.' They can say 'We do not usually give holidays' but they must always listen to any reasons you have why you should be treated as an exception.

Recently the POLICY RESEARCH BUREAU have compiled a report on the importance of holidays, to view this click here

Waiting lists It is very common to be told there is a waiting list for services. You may be told this even when it is agreed there is an assessed need. Where there is an assessed need, in law the Local Authority has a duty to provide a service straight away although in practice this often does not happen. If the delay is lengthy or you feel the need is urgent, you may wish to consider making a formal complaint.

The care plan

Once the Social Worker has gathered enough information through the assessment, s/he then decides which of the child's various needs warrant the provision of services. A plan should then be agreed between Social Services and the family, in order to meet the identified needs.

The plan should give details of:

• What services will be provided For how long the services are required
• What the Local Authority plans to achieve by providing the services
• What each person and agency is expected to do
• Date of next review

Importantly, the care plan should be reviewed regularly to make sure that any services provided remain appropriate.

---

---

---

Charging

Will I have to pay for any services provided?

Local Authorities do have the power to charge for services they provide under the Children Act 1989. It is usually your means as a parent which are assessed rather than your child's and you should not be asked to pay more than you can afford. Each Local Authority will have its own charging policy.

When a child reaches 16, they are assessed in their own right. This means it should be their ability to pay which is taken into account and not the parents.

When should I not be charged?

If you are in receipt of Income Support, no charge should be made for services under the Children Act. Recipients of Working Tax Credit and Child Tax Credit (above the Family element) should also be exempt from charges for Children Act Services.

Arguably, your Local Authority cannot charge for any services which are provided under the Chronically Sick and Disabled Persons Act. If your child has been assessed as being in need of any of these services, s/he is disabled and you are being charged, you should seek further advice.

Also, you should not be charged for advice, information and Social Work Services.

Do I have to pay for services provided to me as a carer?

Services for carers of disabled children are normally provided under the Children Act and the same charging rules apply.

What if I cannot afford to pay the assessed charges?

If you feel you are being charged wrongly or at a level which is more than you can reasonably be expected to pay given your circumstances, you can ask for the charges to be reduced or waived completely. If you are still unhappy with the amount you have been asked to pay you can make a formal complaint.

Direct payments

What are direct payments?

Local Authorities can give payments, instead of services, to allow disabled people and carers to buy in the services they have been assessed as needing. Direct Payments are seen to promote the independence of parents and their disabled children who would like to manage their own social care needs.

If your child is under 16 Direct Payments will usually be made to you as their parent. When a child becomes 16 she or he can receive payments in their own right to allow them to buy in the services they have been assessed as needing.

In the past you could not insist on Direct Payments, however, in England, a request should now be refused only in very limited circumstances. At the moment Direct Payments schemes are not yet mandatory in Wales.

The amount you receive should be enough to allow you to meet all the costs involved, including tax and National Insurance as well as the fee for a police check (should you employ help directly). Social Services will usually deduct an amount from the payments equivalent to what you would have been charged had they arranged the services. Alternatively, Social Services may make the payments in full and ask you to reimburse them any assessed charge.

Any payments you receive must be used to pay for services to meet the assessed needs.

The Department of Health together with the Council for Disabled Children have produced 'A Parent's Guide to Direct Payments'. Copies are available from Department of Health Publications, PO Box 777, London SE1 6XH, Tel. 08701 555 455, Fax. 01623 724 524 e-mail: CLICK HERE

Vouchers

The Carers and Disabled Children Act 2000 has also made provision for a new voucher scheme. The scheme is currently being implemented in England. At the time of writing there were no detailed proposals regarding the introduction of the voucher scheme in Wales, although pilot schemes may be introduced in certain parts of Wales. In effect, the scheme should allow carers and disabled children to receive vouchers for short-term respite breaks. This should mean more freedom to choose when and where to take a break.

Making A Formal Complaint

You have a right to complain about any social service provided by the Local Authority. Complaints can be made about an assessment of whether a child is in need or not, or about the provision or lack of provision of services for your family and disabled child. Some people are worried about making a complaint because they fear that the services already provided will be taken away. You can always request the help of a local parent support group or advocacy service.

---

---

---

Each Local Authority has a 'designated officer' who receives all complaints. In the first instance, you can make either a verbal or a written complaint, although it is advisable to put the complaint in writing or keep a note of your complaint if you telephone. An informal complaint can be made to any officer at the Social Services Department and they will try and sort out the problem. If you prefer, or if the problem is not resolved, you can make a formal complaint. Every Social Services Department should have a leaflet outlining the Complaints Procedure, so you may wish to obtain one.

Once a formal complaint has been made, Social Services have 28 days to give a written response to the complaint. You can request a meeting to explain your complaint, but Social Services do not have to agree to this meeting. If you are still not satisfied, you can request a review hearing before a panel of 3 people. You have 28 days from receiving the Local Authority's response to request a review.

If you are not happy with the decision of the review panel, there are various other options, such as taking the issue up with a local councillor or MP (or Assembly Member if you live in Wales) or complaining to the respective Local Government Ombudsman:

England:

21 Queen Anne's Gate, London SW1H 9BU Tel. (020) 7915 3210 Lo-call Tel. 0845 602 1983 Fax. (020) 7233 0396 Website: http://www.lgo.org.uk/

Wales:

Derwen House, Court Road, Bridgend CF31 1BN Tel. (01656) 661325 Fax. (01656) 658317 e-mail: enquiries@ombudsman-wales.org Website: http://www.ombudsman-wales.org/

The Ombudsman can investigate complaints against principal councils (not town, parish or community councils) and certain other bodies. By law, some kinds of complaint cannot be considered. Examples are personnel complaints and complaints about the internal running of schools.

Judicial Review

If your complaint is very urgent and you cannot wait for the Complaints Procedure to resolve the matter, you can apply to the courts for a Judicial Review. Judicial Review is a procedure where the High Court looks at the way a decision was reached to see if this was legally correct. You can also apply for Judicial Review if you have exhausted the Complaints Procedure and are still unhappy with the outcome. To do this you will need legal assistance. If you have a low income you may qualify for the Legal Help Scheme. Also, some solicitors offer a free first interview.

Before seeking judicial review it may be worth complaining to the Local Authority Monitoring Officer. The Monitoring Officer (usually the Chief Executive or Borough Solicitor) is responsible for ensuring that decisions are lawful and procedures correctly followed.

Some Frequently Asked Questions

My Social Worker has said I should put my disabled child on a register of children with disabilities. What does this mean?

Social Services have an obligation to keep a register of children with disabilities. This is not the same as the Child Protection register and does not suggest in any way that your child is at risk. You do not have to agree to your child's name being added to the register and it does not affect entitlement to services. A register enables Social Services Departments to try and plan services for disabled children more effectively in their area. It is sometimes used as a way of getting relevant information to families of children with disabilities.

My daughter is disabled and I'm wondering if I can get a Blue Badge?

The Blue Badge Scheme (formerly Orange) is a UK arrangement of on-street parking concessions for disabled people. The badge can also be used in many European countries. If you regularly drive your disabled child and s/he has severe walking difficulties, is registered blind, has severe upper limb disabilities or receives the higher rate component of Disability Living Allowance, you may be eligible. You should apply to your local Social Services Department.

Can my Social Worker advise me on which benefits my family are entitled to?

Yes, Social Workers do have a duty to provide advice and guidance. They should explain to you what benefits are available and ensure that you are receiving the benefits to which you are entitled. However, most Social Workers are not benefits experts and they may rely on the Local Authority's Welfare Rights Service or similar advice agency to help you. They may also direct you to a voluntary organisation, such as the Family Fund, for further help.

Do I have a right to see my child's records?

Under the Data Protection Act 1998 professionals and agencies have a duty not to disclose information about disabled children and their families without the consent of the subject. This applies to children as well as adults, provided that if they are under 16 'they have the ability to understand the choices and their consequences'. Even though there is a duty not to disclose the public body concerned (eg Health or Local Authority) still retain a discretion to allow access to the information. In most cases parents should have no difficulty in seeing their child's records. Guidance also states that advocates should be given access to relevant information concerning the person they're representing.

---

---

---

Further information and advice

or further information, please contact your local Carers Centre, Citizens Advice Bureau, Law Centre or Disabled Person's Advice Centre.

Tips for attending meetings with Social Services

Be prepared:

for example, you might want to have visited a school or a residential home, if you are planning to talk about placements.

Keep copies of everything:

for example, letters you have written about your child to the authorities, as well as those they send to you. Keep everything in a file, making sure you read everything you think might be relevant before the meeting to refresh your memory.

Make notes:

it is easy to forget something so having a few notes handy at a case conference will help to make sure you cover all the points you want to make. Listen to what the professional workers have to say and make notes of what is said.

Take someone with you:

if you have a partner, make sure you both attend the case conference. If that is not possible, or you are a single parent, take a friend or someone from a local support network.

Do not be frightened to ask:

if you do not understand what is being said, ask questions until you do.

Keep calm:

do not lose your temper if things are going wrong. Try and give reasoned counter arguments.

Follow up:

compare notes and draw up a summary of the main points made at the meeting, what was agreed, and what still needs agreement to be reached.

---

 

---

next: Legal Help for ADHD-Related Issues in UK
~ back to adders.org homepage
~ adhd library articles
~ all add/adhd articles