Dr. Amuleru-Marshall - S Handout, July 2012

BEHS 640
HUMAN DEVELOPMENT
Zuri Amuleru-Marshall, Ph.D.
Professor
Department of Behavioral Science
1
Human Development
Across the Life Span
Why do you need to know?

To give sound advice
To determine developmental status
Doctors are often looked to for advice on whether
or not an instance of behavior is abnormal and
whether or not a child/person is progressing
normally.
To recognize age appropriate behaviors

In order to treat patients with empathy, the doctor will benefit
from knowing what needs and problems are characteristic at
different ages, and what reactions to medical care are
common.
3
For example
Common Problems
1. Twice in the last year, my 2 year old
daughter, Carol, awakened screaming,
sweating and confused. She was
hyperventilating; her pupils were dilated; and
her pulse was rapid. I could not calm her.
Once she was fully awake, she stopped
screaming and fell straight to sleep. What
was wrong with her, doctor?
Each week, for children 1-3 years of

age:
7% will experience a night terror . This
occurs during non-REM, deep sleep.
10% will experience a nightmare. This
occurs during REM sleep, and the child
often
remembers the dream.
Most prevalent betw 4-6
Nearly half resist going to bed.
Problems settling and waking up during
the night are not unusual.

5
2. Carol just doesnt seem to know how to play

with other children. It is not that they fight,
but she just carries on playing with her own
toys instead of sharing them with the other
children. I cant work it out. I dont want her
to be a loner. Do you think she will grow to
be antisocial? Do you think shell have
problems when she goes to school?
Stages of Play
Solitary Play
(sensorimotor)
<18 mos of age
Parallel Play
(symbolic)
18 mos - 2 yrs
Cooperative Play
3 - 4 yrs
(associative or imaginary)
7
Aspects of Human Development

Physical Development
Maturation and Growth
Motor Skills
Cognitive Development
Thought Processes
Information Processing
Language Acquisition
Affective Development
Attachment
Emotional Development
Social Development
Interpersonal Relationships
Development of Self
Gender Identity
Moral Development
Many Disciplines Contribute to an

Understanding of Human Development
Psychology
Biology
Sociology
Medicine
Anthropology
Philosophy
History
10
Periods of Development
CONCEPTION
Prenatal Period
Infancy (birth to 1)
Toddlerhood (1-3)
Early Childhood (3-6)
School Age (6-12)
Adolescence (12-18)
Young Adulthood
Middle Age
Old Age
DEATH
11
Three Major Issues

I.
Nature vs Nurture
II. Continuity vs Stages
III. Stability vs Change
12
Nature vs Nurture
How much is human development
influenced by our genetic inheritance
and how much by our experience?
13
John Locke (End 17th century)

The mind of a newborn infant is a tabula rasa.
Passive
Receptive
Jean Jacques Rousseau (Mid 18th century)

The child is endowed with an innate moral sense a noble
savage.
Active
Man is born free, yet we see him everywhere in chains.
14
John B. Watson and B.F. Skinner: Human nature is

completely malleable.
Give me a dozen healthy infants, well-formed, and

my own specified world to bring them up in, and Ill
guarantee to take any one at random and train him
to be any type of specialist I might select -- doctor,
lawyer, artist, merchant-chief, and, yes, even beggarman and thief, regardless of his talents, penchants,
tendencies, abilities, vocations, and race of his
ancestors. (Watson, 1930, p. 104)
15
Richard J. Herrnstein & Charles Murray:
There are substantial individual and group differences in

intelligence; these differences profoundly influence the
social structure and organization of work in industrial
societies; and they defy easy remediation.
The Bell Curve: Intelligence and Class Structure in

American Life, 1994
16
Nature and nurture interact.

Nature via nurture.
Nurture nurtures nature.
Development is shaped by genetic

and environmental factors.
17
Continuity vs Stages
Is development a gradual continuous

process, or does it proceed through a
sequence of stages?
What about critical periods - crucial

time periods during which specific
events must occur if development is to
proceed normally?
18
Maturational aspects of development are

thought to proceed in predetermined order.
Maturational changes involve growth processes that
produce orderly changes, whose timing and
patterning are relatively independent of exercise or
experience.
Only grossly abnormal environments will disrupt
maturational changes, i.e. children reared with no
human stimulation.
19
Stage theorists posit that development occurs in

a predictable series of steps.
The rate at which persons move through these stages
may vary.
Culture impacts development.
Interplay of maturation with stage attainment
20
Stability vs Change
Do our early personality traits exist
through life or do we become different
persons as we grow older?
The New York Longitudinal Study, Thomas &
Chess 1986
Generally, the first two years of life provide a poor
basis for predicting a persons eventual traits. As
people grow older, however, continuity of
personality gradually increases.
21
Dimensions of Temperament
These traits have been found to be
relatively stable from infancy through
adulthood.
1. Activity Level
5. Intensity of reaction
2. Regularity of biological
functions
6. Threshold of
responsiveness
3. Approach to novel
stimuli
7. Mood - Positive,
Negative, Neutral
4. Adaptability to
environmental change
8. Distractibility
9. Attention span and
persistence
22
Periods of Development
CONCEPTION
Prenatal Period
Infancy (birth to 1)
Toddlerhood (1-3)
Early Childhood (3-6)
School Age (6-12)
Adolescence (12-18)
Young Adulthood
Middle Age
Old Age
DEATH
23
When the Bough Breaks

Objectives 1.1, 1.5, 1.6, 1.7
FRONTLINE
PBS Video FROL315
For information, call 1-800-424-7963
or
www.shoppbs.org
24
Infancy and Toddlerhood

Birth to Age 3
25
The Competent Newborn

REFLEXES
Rooting
Sucking
Grasping
Moro Reflex
Disappears with
maturation of
cerebral cortex (3
months)
26
Rooting Reflex
Sucking Reflex
27
Grasping Reflex
28
Moro (startle) Reflex
29
The Newborn: Sensitive to the

environment and able to learn
Newborns can
Track moving objects (poor visual
acuity)
Orient to a loud noise
Distinguish between human voice and
other sounds
Show preferences
sweeter fluid; own mothers milk
sweet odors to noxious odors
attracted to stimuli with characteristics such as
curved lines, high contrast, movement, edges,
and complexity (human face)
30
Which will be more attractive?
Babies less than 2 months of age spend more time

looking at B than A. B and C were looked at for the
same length of time.
31
Rapid Physical Growth
300% increase in weight in 1st year
Sequence of motor skills almost universal
Rate of movement through sequence
varies
Individual differences
Cultural differences
Milestones for Child Development
32
General Guidelines for

Development
Estimating Developmental Status
DENVER II compares a childs performance on a
variety of tasks (125) to the performance of other
children the same age.
Four Scales
Gross Motor
Fine Motor Adaptive

Personal - Social
Language
Frankenburg WK, Dodds J, Archer P, et al. The Denver II Training Manual. Denver Developmental Materials, Inc., 1992 33
Childs age:
2 yrs, 9 mos
Denver II: The Age Line

Age Scale in Months
8-15-05
12
15
The child is 13.5 months old. The date of the test is August 15, 2005.
Age is adjusted for prematurity if child (1) was born more than 2 weeks
early and (2) is less than 2 years of age
Denver II: Interpreting Items
Each item is represented by a bar.
Bar shows the age at which 25%, 50%, 75%, and

90% of the standardization sample passed that item.
Age Scale in Months
12
25%
50%
15
75%
90%
.
WALK WELL
Percent of normal children passing item
Childs age:
2 yrs, 9 mos
Normal
No delays.
One caution.
MONTHS
12
WALK WELL
STOOP AND
RECOVER
STAND ALONE
STAND- 2
SECONDS
GET TO SITTING
PULL TO
STAND
STAND
HOLDING ON
F
F
F
F
SIT-NO
SUPPORT
PULL TO SIT- NO
HEAD LAG
ROLL OVER
CHEST UPARM SUPPORT
BEAR WEIGHT
ON LEGS
SIT-HEAD
STEADY
HEAD
UP 90
HEAD UP
45
Excerpt from Denver II

Gross Motor Scale
Birth to 12 months
C
C
DD
LIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
12
Developmental Red Flags

1.
Abnormal or absent primitive reflexes at

birth
2.
Persistent fisting at 3 months: neuromotor

deficits
3.
Failure to reach for objects at 6 months:

motor, visual, cognitive deficits
4.
Absent smile at 3 months: visual loss,

attachment problems, maternal depression, child
abuse/neglect
5.
Absent babbling at 6 months: hearing deficit
39
Developmental Red Flags

6.
Persistent mouthing of objects at 12

months: cognitive deficits
7.
Advanced non-communicative speech (e.g.

echolalia) at 1.5 years: pervasive
developmental disorder, cognitive deficits
8.
Regression from any previously acquired

skills
9.
Lack of normal developmental progression

40
Affective Development
Attachment
An infants tendency to seek closeness to
particular persons and to feel more secure
in their presence.
Sources of attachment provide
Secure base
Safe haven
Attachment or Bonding??
41
Conditions Associated with

Attachment
Cloth and Wire Surrogate Mothers
H. Harlow, 1959
42
Not exclusively associated with feeding,

as originally thought.
Is affected by:
comforting body contact
familiarity, predictability, and reliability
sensitive responsiveness of parent
childs temperament
43
Temperament - Nine Relatively

Stable Traits
Activity Level
Regularity of Biological Functions
Approach to Novel Stimuli
Adaptability to Environmental Change
Intensity of Reaction
Threshold of Responsiveness
Quality of Mood
Distractibility
Attention Span or Persistence
New York Longitudinal Study,1986
44
Normal Responses to SEPARATION

Stranger Anxiety (6-9 months)
Cognitive Advance
Cultural Variations
Separation anxiety (6-9 months)
Understand cause and effect
Learns via experience that parent will
return
Long term separation
Protest - Crying and Acute Distress
Despair - Grief
Detachment Apathy
45
Categories of Attachment
(Study of U.S. Infants and Mothers)
1. Securely Attached
Child seeks interaction with mother upon her
return.
2. Insecurely Attached: Anxious

Avoidant
Child avoids interaction with mother upon her
return. (Comfort denied to child.)
46
3. Insecurely Attached: Anxious

Resistant
Child shows resistance when mother returns.
Child may seek and then resist physical
interaction. (Parental inconsistency)
4. Insecurely Attached: Disorganized

Child exhibits confusion when mother returns.
Child may avoid, resist, or be fearful of mother.
(Abuse, Parental Depression)
47
What are the possible effects of

insecure attachment in early
childhood?
Research tends to indicate that:
Secure attachment predicts social competence
Severe attachment deprivation (abuse, extreme
neglect, lack of stimulation) often results in withdrawn,
frightened, socially incompetent, and perhaps
speechless children.
Traumatic, prolonged separations may result in
anaclitic depression, in which the child becomes
withdrawn and unresponsive.
Lack of human contact and stimulation can result in
Failure to Thrive syndrome
48
Toddlers
Slow down in physical growth
Decrease in appetite
Struggle for autonomy and separateness
from parents Terrible Twos
Fears
Gender Identity and Role Definition
Move from Solitary Play in Infancy to Parallel
Play , then to Cooperative Play
Move from Sensorimotor Play in Infancy to
Symbolic Play , then to Imaginary Play

49
Cognition: All of the mental activities
associated with thinking, knowing,
remembering, learning, processing,
and communicating information.
50
Language Development
Fetus perceives, discriminates, and responds
to sounds in utero (7 months gestation)
Approximate Age
2-3 months
3-4 months
10 months
Stage
Cooing
Babbling
12 months
Babbling Household Language

Jargon
One-word stage
24 months
Two-word telegraphic stage
24+
Language develops rapidly into

complete sentences
51
Receptive language
precedes
expressive language
52
Four Language Subsystems

1. Phonemic system sounds
2. Semantic system meanings

3. Syntactic system grammar
4. Pragmatic system social rules
53
Language delay might signify

Hearing Impairment
Mental retardation (most common cause)
Pervasive Developmental Disorders
Autism
Retts Syndrome
Childhood Disintegrative Disorder
Pure language disorders

Developmental apraxia of speech - disorder of
expressive language
Maturational/constitutional language delay

(usually male, family history, may resolve by 5)
54
General Cognitive
Development: Jean Piaget
4 factors influence cognition
1.Nervous system maturation
2.Experience or environmental stimulation
3.Social transmission of information
4.Equilibration: A cognitive process in which
existing constructs are changed as a result of
new experiences, resulting in an advanced
state of cognitive balance.
ASSIMILATION
ACCOMMODATION
55
Piagets Four Stages of

1. Sensorimotor Stage Birth to 2
Experiencing the world through senses and

actions
2. Preoperational Stage 2-6
Representing things with words and images

Lacking logical reasoning
3. Concrete Operational Stage 7-11
Thinking logically about concrete events
4. Formal Operational Stage 12

adulthood
Abstract reasoning
56
1. Sensorimotor Stage Birth to 2

Primary Circular Reactions
Reflex action and response both involve babys own
body, i.e. sucking thumb
Secondary Circular Reactions

Action gets response from other person or object,
leading to repetition, i.e. cooing
Tertiary Circular Reactions (12 months +)

Planned action gets pleasing result, leading to similar
new actions, i.e. step on squeaky toy, squeeze
squeaky toy
57
Stranger Anxiety emerges: 6-9 months
Separation Anxiety emerges: 6-9 months

Object Permanence: 7-9 months
58
Object Permanence
59
Piaget - Sensorimotor Stage.ram
2. Preoperational Stage 2-6

Representations - objects represented
by words or images
Ability to pretend
Egocentric thought
Centering attends to a single obvious
feature without considering other
features
Lack of Conservation Abilities
The understanding that the amount of a substance
remains the same even when its form is changed.
61
Conservation
62
3. Concrete Operational Stage

7-12
Logical thinking about objects and events
Mental manipulation of objects and
processes
Ability to consider more than one
dimension at a time (decentrate)
THEREFORE,
Conservation
63
4. Formal Operational Stage

12 to adulthood
Abstract thinking
Hypothesizing
Higher order thinking
Synthesizing
Analyzing
Evaluating
64
Childhood
Early Childhood and Middle Childhood
3-12 Years
65
Development in Childhood
Improved gross motor and fine motor
development
Balance and control allow for more complex
sports, games, and activities
By age 7, brain is 90% of adult weight.

Handedness established (by age 7)
66
Sleep needs change from napping at age

3-4; resistance to napping at 5-6. Ten
hours of sleep at age 8, decreasing to 8 by
age 10.
Pubertal changes
Changes in hormonal production
Growth spurt
Girls 10-13
Boys 13-15
67
Primary and secondary sex

characteristics develop.
Primary: The body structures that make
sexual reproduction possible (testes,
ovaries).
Secondary: Nonreproductive sexual
characteristics, such as breasts and hips,
body hair, male voice quality, etc.
Menarche
68
Age Trend at Menarche
Bellis, M A et al. J Epidemiol Community Health 2006;60:910-911

Copyright 2006 BMJ Publishing Group Ltd.
Piaget
Early childhood Preoperational Stage
Middle Childhood Concrete Operational Stage
Society - Formal Schooling begins

Moral Development Kohlbergs Stages of
Moral Reasoning
70
Kohlbergs Stages of Moral Reasoning

Obeys rules to avoid punishment
Stage 2: Reward Orientation

Conforms to obtain rewards and favors
Conforms to avoid disapproval
Stage 4: Authority Orientation
CONVENTIONAL
Stage 3: Good Boy/Good Girl
PRECONVENTIONAL
Stage 1: Punishment Orientation
Upholds social rules to avoid censure and guilt

71
Stage 5: Social Contract Orientation
Stage 6: Ethical Principle Orientation

Actions guided by self-chosen ethical principles,
which usually value justice, dignity, and equality
principles upheld to avoid self-condemnation.
POSTCONVENTIONAL
Actions guided by commonly agreed upon

principles, as essential to the public welfare
principles upheld to retain respect of peers, and
thus, self-respect.
72
Percent in Stages 1 and 2

100
90
80
70
60
50
40
30
20
10
0
80
18
3
age 10
age 1618
age 24
Moral reasoning at this level declines sharply with age.

73

100
90
80
70
60
50
40
30
20
10
0
90
80
18
age 10
age 1618
age 24
Moral reasoning at this level increases with age,

and is the predominant level from adolescents onward.
74
Only a small percentage of the

participants studied reached Stage 5.
So few reached Stage 6 that it was
dropped from the scale.
Longitudinal studies were conducted in the U.S., Taiwan,
Turkey, India, and Nigeria.
75
Childhood Demographics
Preschool population in US becoming nonwhite
By middle of this century, no ethnic or racial group will

constitute a majority.
One in five children in the US lives in poverty

(One in four minority children)
Single most powerful predictor of health status

for young children - POVERTY
Underlying cause of preventable illness
76
Child Poverty Associated With...

Poor nutrition
Higher risk for chronic conditions
Increased exposure to environmental
toxins
Hazardous housing conditions
Increased family stress
Increased exposure to drugs and violence
Lack of access to healthy options
Lack of access to health care
77
Neonatal Period
Birth- 28 days
Infant Deaths, U.S.

(under 1 year of age)
Leading Causes
Congenital/chromosomal abnormalities
Disorders related to LBW or preterm

Sudden Infant Death Syndrome (SIDS)
Maternal complications of pregnancy
Accidents
US Infant Mortality Rate: 6.4 per 1000 live births
US Ranked 29th worldwide
IMR Rankings above the U.S.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
11.
11.
11.
15.
16.
Singapore
Hong Kong
Japan
Sweden
Norway
Finland
Spain
Czech Republic
France
Portugal
Germany
Greece
Italy
Netherlands
Switzerland
Belgium
2.0
2.5
2.8
3.1
3.2
3.3
3.5
3.7
3.9
4.0
4.1
4.1
4.1
4.1
4.2
4.3
17. Denmark
18. Austria
18. Israel
20. Australia
21. Ireland
21. Scotland
23. England & Wales
24. Canada
25. Northern Ireland
26. New Zealand
27. Cuba
28. Hungary
29. Poland
29. Slovakia
29. United States
4.4
4.5
4.5
4.7
4.9
4.9
5.0
5.3
5.7
5.7
5.8
6.6
6.9
6.9
6.9
Leading Causes of Child Death,

U.S.
Age 1-4
1. Unintentional Injuries
2.
3.
4.
5.
Age 5-14
1. Motor Vehicle
2. Pedestrian Incidents
3. Drowning
Motor Vehicle
Drowning
Pedestrian Incidents
Congenital Abnormalities
Homicide
Malignant Neoplasms
Diseases of Heart
2.
3.
4.
5.
Malignant Neoplasms
Congenital Abnormalities
Homicide
Suicide
81
Adolescence
12?? 18??
Tension between biological maturity
and social independence.
82
History of Adolescence
Childhood
Adulthood
Nonexistent until Industrial Revolution

Child Labor Laws (1916, 1938)
Ruled unconstitutional, 1918
Mandatory Schooling
Age expectation for independence and
responsibility extended Psychosocial
Moratorium (Erikson)
83
Primary Developmental Issues

of Adolescence
Independence
Family vs Peers
Sharing vs Privacy
Idealization vs Devaluation of others
Freedom vs Control
Choice of sexual object / Intimacy
Style of functioning
Identity Who am I?
Physically, sexually, socially, vocationally
84
Physical Developmental
Variation in levels of development
Boys
14
Girls
12
85
Formal Operational Stage
Problem-solving characterized by
Systematic searching for solution
Hypothesizing
New level of social awareness thinking

about thinking
Abstract thinking issues of religiosity, good
and evil, hypocrisy, social welfare, etc.
Questioning
86
Special Challenges to Health

Weight
Overweight BMI for age/sex >85th <95th %ile
Obese BMI for age/sex >95th %ile
Risk-taking
Percentage of High School Students Who Were

Overweight,* by Sex and Race/Ethnicity,** 2007
100
Percent
80
60
40
20
15.8
15.1
16.4
14.3
Female
Male
White
19.0
18.1
Black
Hispanic
0
Total
* Students who were > 85th percentile but < 95th percentile for body mass index, by age and sex, based on reference data.
** B, H > W
National Youth Risk Behavior Survey, 2007
Percentage of High School Students Who Were

Obese,* by Sex** and Race/Ethnicity,*** 2007
100
Percent
80
60
40
20
16.3
13.0
18.3
16.6
Black
Hispanic
10.8
9.6
0
Total
Female
Male
White
* Students who were > 95th percentile for body mass index, by age and sex, based on reference data.
** M > F
*** B, H > W
Risk-Taking Among Adolescents

Sense of invulnerability leads to excessive
risk-taking It cant happen to me.
Drug Experimentation
Increase in cigarette use among high
schoolers
High rates of alcohol use
Illicit drug use marijuana, cocaine, heroin,
designer drugs, prescription drugs
90
Early Sexual Activity

Nearly 1/2 of females and more than 1/2 of
males sexually active in high school
Sexually transmitted diseases
AIDS (increasing dramatically in
adolescents)
Pregnancy
High rate in U.S. (49 per 1000)
Lowest in Japan (4 per 1000)
Under 10 per 1000 in Denmark, Finland, France,
Germany, Italy, Netherlands, Spain, Sweden,
Switzerland
91
Percentage of High School Students Who Ever

Had Sexual Intercourse, 1991 2007
100
Percent
80
60
54.1
53.0
53.1
48.4
49.9
1997
1999
45.6
46.7
46.8
47.81
2001
2003
2005
2007
40
20
0
1991
1
1993
1995
Decreased 1991-2007, p < .05
National Youth Risk Behavior Surveys, 1991 2007
Percentage of High School Students Who Used

a Condom During Last Sexual Intercourse,* by
Sex** and Race/Ethnicity,*** 2007
100
80
68.5
Percent
61.5
60
67.3
61.4
59.7
54.9
40
20
0
Total
Female
Male
White
Black
Hispanic
* Among the 35.0% of students nationwide who had sexual intercourse with at least one person during the 3 months before
the survey.
** M > F
*** B > W
Weapons
8% of females and 29% of males carried
weapon in the past 30 days
Violence
Disinhibitions created by drug use
Encouragement by peers
Influence of media
94
Percentage of High School Students Who Carried

a Weapon,* by Sex** and Race/Ethnicity, 2007
100
Percent
80
60
40
28.5
20
18.0
18.2
17.2
18.5
White
Black
Hispanic
7.5
0
Total
Female
Male
* For example, a gun, knife, or club on at least 1 day during the 30 days before the survey.
** M > F
American Psychological Association

Press Release, May 2003
Violent Music Lyrics Increase Aggressive Thoughts and
Feelings, According to a New Study
The violent songs increased feelings of hostility
without provocation or threat
Aggressive thoughts can influence perceptions of
ongoing social interactions, coloring them with an
aggressive tint instigating a more aggressive
response than would have been emitted in a
nonbiased state
C. A. Anderson, N. L. Carnagey, and J. Eubanks, Exposure to Violent Media: The Effects of Songs with
Violent Lyrics on Aggressive Thoughts and Feelings, Journal of Personality and Social Psychology, Vol.
84, No. 5.
96
Adolescent Mortality, Age 15-19

Three leading causes of death (76% of all
deaths):
Accidents - unintentional injuries
Motor Vehicle Accidents (40%)
Homicide (13.7%)
Males 3-4x Females
Blacks 7-8x Whites
Suicide (10.9%)
Higher for males
Native American, Hispanics, Whites, Blacks
97
Psychosocial Development
Erik Erikson: Each stage of life has its own
psychosocial task a crisis that needs
resolution.
The epigenetic principle: Each builds on the
previous one(s)
Resolution of each crisis = Maturation
With maturation, lower stages aquire new
meanings
In adolescence, the task is Identity vs Role

Confusion
98
Eriksons Stages of
Psychosocial Development
Appr.
Age
Infancy
Toddler
Task
Trust vs Mistrust
If needs are dependably met,
infants develop a sense of basic
trust
Autonomy vs Shame and Doubt

Toddlers learn to exercise will
and do things for themselves, or
they doubt their abilities.
99
Appr.
Task
Age
Preschool Initiative vs Guilt
er
Preschoolers learn to initiate tasks
3-5
and carry out plans, or they feel

guilty about efforts to be
independent.
Elem.
School
6-puberty
Competence (Industry) vs Inferiority

Children learn the pleasure of
applying themselves to tasks, or
they feel inferior.
100
Appr.
Age
Adolescen
ce
Teen into
20s
Young
Adult
20s-40s
Task
Identity vs Role Confusion

Teenagers work at refining a
sense of self by testing roles and
then integrating them to form a
single identity, or they become
confused about who they are.
Intimacy vs Isolation
Young adults struggle to form
close relationships and to gain
the capacity for intimate love, or
they feel socially isolated.
101
Appr.
Age
Middle
Adult
40s-60s
Task
Generativity vs Stagnation
The middle-aged discover a sense
of contributing to the world, such
as through family and work, or
they may feel a lack of purpose.
Late Adult Integrity vs Despair

Late 60s +
When reflecting on his or her life,
the older adult may feel a sense of

satisfaction or failure.
102
Mental Disorders
of Childhood and Adolescence
Diagnostic and Statistical Manual of Mental
Disorders (DSM): A publication of the
American Psychiatric Association that
provides systematic descriptions of mental
disorders.
1. Mental Retardation
2. Learning Disorders
3. Conduct Disorders
4. Attention Deficit/Hyperactivity Disorder
5. Pervasive Developmental Disorders
103
Mental Retardation:
Mild, Moderate, Severe, Profound
A.
Significantly subaverage intellectual functioning: an

IQ of approximately 70 or below on an individually
administered IQ test (for infants, a clinical judgment of
significantly subaverage intellectual functioning
AND
B. Concurrent deficits or impairments in present
adaptive functioning (i.e., the persons effectiveness
in meeting the standards expected for his or her age
by his or her cultural group) in at least two of the
following areas: communication, self-care, home
living, social/interpersonal skills, work, leisure, health,
and safety.
AND
C. The onset is before age 18 years.
104
Intelligence Tests
Mean
Standard
Deviation
Wechsler Adult
Intelligence
Scale (WAIS)
100
15
Wechsler
Intelligence
Scale for
Children (WISC)
100
15
Stanford-Binet
Intelligence
Scale
100
16
105
Mental Retardation Degrees of

Severity
# SD
IQ
below
Range mean
Behavioral Description
MILD
(appr 85%)
70-55
2-3
Educable: basic academic

skills, usually employable
MODERATE
(appr 10%)
55-40
3-4
Trainable: self-help skills,

can work under close
supervision, limited social skills
SEVERE
(appr 3-4%)
40-25
4-5
Limited language, self-care with

intensive training, constant
supervision
PROFOUND
(appr 1-2%)
below
25
6+
Most have underlying

neurological condition; may not
develop communication or self
help skills; total care
106
Learning Disorders
A. The individuals achievement on individually
administered, standardized tests in reading,
mathematics, or written expression is
substantially below that expected for age,
schooling, and level of intelligence.*
AND
B. The learning problems significantly interfere
with academic achievement or activities of
daily living that require reading,
mathematical, or writing skills.
*Substantially below Discrepancy of more than 2 SDs
107
Conduct Disorders:
Mild, Moderate, or Severe
A. A repetitive and persistent pattern of behavior
in which the basic rights of others or major
age-appropriate societal norms are violated,
as manifested by the presence of three (or
more) of the following criteria in the past 12
months, with at least one criterion present in
the past 6 months:
Aggression to people and animals

Destruction of property
Deceitfulness or theft
Serious violations of rules
AND
108
B. The disturbance in behavior causes clinically

significant impairment in social, academic,
or occupational functioning.
AND
C. If the individual is age 18 years or older,
criteria are not met for Antisocial Personality
Disorder.
Childhood Onset At least one criterion prior to age 10
Adolescent Onset Absence of any criteria prior to age
10
109
Attention Deficit/Hyperactivity
Disorder (ADHD)
A.
Either (1) or (2):

1. Six or more specific symptoms of inattention
have persisted for at least 6 months to a degree
that is maladaptive and inconsistent with
developmental level.
2. Six or more specific symptoms of hyperactivityimpulsivity have persisted for at least 6 months
to a degree that is maladaptive and inconsistent
with developmental level.
AND
110
B. Some hyperactive-impulsive or inattentive

symptoms that caused impairment were
present before age 7 years
C. Some impairment from the symptoms is
present in two or more settings (e.g. at
school, work, home)
D. There must be clear evidence of clinically
significant impairment in social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively
during the course of another mental
disorder.
111
ADHD, Combined Type

Both criteria A1 and A2 are met for the past 6
months
ADHD, Predominantly Inattentive Type

ADHD, Predominantly HyperactiveImpulsive Type
112
Pervasive Developmental
Disorders: Autism
A1. Qualitative impairment in social
interaction
Nonverbal behaviors (eye contact, facial exp)
Peer relationships
Sharing joy, pleasure, interests of others
A2. Qualitative impairments in

communication
Development of spoken language
Initiating and sustaining conversation
Stereotyped or idiosyncratic language
Imaginative and/or imitative play
113
Autism, cont.
A3. Restricted, repetitive, stereotyped
pattern of behaviors and interests
Preoccupation with stereotyped interests

Inflexible adherence to specific nonfunctional
routines or rituals
Motor mannerisms (hand or finger flapping or
twisting, complex whole body movements)
Persistent preoccupation with parts of objects
B. Onset prior to age 3
Usually evident and diagnosed by age 1
C. Not Retts or CDD

114
Pervasive Developmental
Disorders: Aspergers Syndrome
1. Qualitative impairment in social
interaction
1. Nonverbal behaviors (eye contact, facial exp)
2. Peer relationships
3. Sharing joy, pleasure, interests of others
2. Restricted, repetitive, stereotyped

pattern of behaviors and interests
1. Preoccupation with stereotyped interests
2. Inflexible adherence to specific nonfunctional
routines or rituals
3. Motor mannerisms (hand or finger flapping or
twisting, complex whole body movements)
4. Persistent preoccupation with parts of objects
115
Aspergers Syndrome, cont.

C. The disturbance causes clinically
significant impairment in social,
occupational, or other areas of functioning.
D. No clinically significant general delays in
language
E. No clinically significant delays in cognitive
development, self-help skills, or curiosity
about the environment
Onset later than autism
Usually males
Marked deficits in
pragmatics and prosody
of language
116
Pervasive Developmental Disorders:

Retts Syndrome
A.Normal prenatal and perinatal development
Normal psychomotor development up to 5 months
Normal head circumference at birth
B.Onset after 5-8 month period of normal
development
Deceleration of head growth (5-48 months)
Loss of purposeful use of hands (hand wringing)
Loss of social interaction
Poorly coordinated gait or trunk movements
Severely impaired language and psychomotor
development
Females
Severe or Profound Mental Retardation

117
Pervasive Developmental Disorders:

Childhood Disintegrative Disorder
A. Normal development for at least 2 years
B. Clinically significant loss of previously
acquired skills (before age 10)
Language, social skills, play, motor skills

Bowel and bladder control
C. Abnormalities in functioning
Males
Severe Mental Retardation

Onset is usually between ages 3 and 4
118
Adulthood
Early 20-40
Middle 40-65
Late 65+
119
Phases of Adult Development

Move is away from age-based stage
theories to important life events.
Marriage and
remarriage
Parenthood
Establishing career
Vocational changes
Divorce
Empty nest
Elastic nest
Relocation
Retirement
Loss
Loss of
Independence
Chronic Illness
Life Choices
120
Physical Changes
Physical abilities peak in early
adulthood.
Muscular strength
Reaction time
Sensory keenness
Cardiac output
Changes not usually perceived, unless

strenuous activity is attempted.
121
Mid-Life Milestones
Menopause among women
Gradual decline in sexual functioning
Sperm count, testosterone level, speed of
erection, force of ejaculation, and ability to
control sexual performance
Disability
Chronic Conditions
122
Geriatric Health
The Elderly: A Growing Subgroup
Life Expectancy at Birth
Year
Males
Females
1900
46.4
49.0
1930
58.0
61.3
1960
66.7
73.2
1990
71.4
78.9
2020
72.7
80.1
2050
73.6
81.0
123
Proportion of U.S. Population Over 65

Percent of Population
100
80
60
40
20
0
3 mil
22
4
1900
13
1991
31 mil
2030
66 mil
124
Comparison of Children and Elderly in

U.S. Population
Actual and Projected Distribution of Children and
Elderly in U.S. Population
60
Percent
50
40
40
28
30
20
21
2030
2050
22
11
4
10
0
22 21
1900
1980
Children 0-17
Elderly 65+
125
Female Life Expectancy Increasing

More Rapidly than Male LE
Number
Number of Men per 100 Women

90
80
70
60
50
40
30
20
10
0
83
74
64
53
40
65-69
70-74
75-79
80-84
85+
Age Groups
126
The Slow Decline of the Bodys

Physical Capacities During Adulthood
Diminished
Reserve
Insel & Roth, 1976
127
The Senses and Age

VISION
SMELL
HEARING
128
Cognitive Changes
CONTROVERSIAL
Which is true???
You cant teach an old dog new tricks?
Youre never too old to learn?
In youth we learn, in age we
understand.
129
Early adulthood is the peak time for

some kinds of learning and
remembering.
Recall vs Recognition
130
Aging and Memory: Tests of Recall
131
Recall vs Recognition
132
The more meaningful the information, the

less memory decline
More existing knowledge
More conceptual and experiential linkages
Crystallized intelligence increases with age.

(ones accumulated knowledge as reflected in
vocabulary and analogies tests)
Fluid intelligence decreases with age.
(ones ability to reason speedily and abstractly
when solving novel logic problems)
133
Health Problems
At turn of the century, the elderly
suffered and died primarily from acute
illnesses.
At this time, the elderly have fewer

acute illnesses, but suffer and die from
chronic illnesses.
134
Chronic Conditions Reported

Percent of Persons 70+ Who Reported
Selected Chronic Conditions
Chronic Condition
Women Men
Arthritis
63.3
49.5
Hypertension
39.6
31.5
Heart Disease
24.1
30.0
Diabetes
10.4
11.6
Respiratory Diseases
10.3
11.0
Stroke
7.6
10.4
Cancer
2.3
6.0
135
Leading Causes of Death , Age 1-24

1950-2009
Age 1-24
2. Homicide
3. Suicide
4. Cancer
5. Heart Disease
2009
136
Leading Causes of Death, Age 25-44

1950-2009
2. Cancer
3. Heart Disease
4. Suicide
5. Homicide
Age 25-44
2009
137
Leading Causes of Death, Age 45-64

1950-2009
Age 45-64
1. Cancer
2. Heart Disease
4. Chronic Lower Respiratory Disease

5. Chronic Liver Disease & Cirrhosis
2009
138
Leading Causes of Death, Age 65+

1950-2009
Age 65+
1. Heart Disease
2. Cancer
Stroke
3. Chronic Lower Respiratory Disease
4. Cerebrovascular Diseases
5. AlzheimersDisease
2009
139
SUICIDE
A Growing Worldwide Concern
140
The World Health Organization reports

that
In the last 45 years suicide rates have
increased by 60% worldwide.
Suicide is now among the three leading
causes of death among those aged 1544 (both sexes).
Suicide attempts are up to 20 times
more frequent than completed suicides.
141
World Health Organization, 2002

142
World Health Organization, 2000

143
WHO reports that

Although suicide rates have traditionally
been highest among elderly males, rates
among young people have been increasing
to such an extent that they are now the
group at highest risk in a third of all
countries.
144
The Centers for Disease Control and

Prevention reports that
More people die from suicide than from
homicide. In 2009, there were 16,591
homicides, and 36,547 suicides.
Overall, suicide is the 10th leading cause of
death for all Americans, and is the 3rd leading
cause of death for young people aged 15-34.
Males are four times more likely to die from

suicide than are females. However, females are
3x more likely to attempt suicide than are
males.
145
U.S. rate: 11.1 per 100,000
146
YRBSS,
CDC, 2008
147
YRBSS,
CDC, 2008
148
Suicide Rates for Men, Women, and the

Nation, USA, 1933-1998
American Association of Suicidology, 2001

149
Suicide Rates for the Young (15-24), Elderly

(65+), and the Nation, USA, 1933-1998
American Association of Suicidology, 2001

150
Statistical Risk Factors for Suicide (U.S.)

Demographic
Males, in general
Gays, lesbians, bisexuals
Unmarried
Living alone or socially
isolated
Whites, Native Americans
Unemployed
Physicians, psychiatrists,
psychologists, dentists,
police officers, attorneys
Clinical
Major depression
Substance Abuse
Chronic pain
Terminal illness
Loss of physical functioning
Loss of body parts
HIV AIDS
Dialysis, health dependency
Individual: Prior attempts, Family history of suicide, abuse, drug

abuse, cultural or religious beliefs
F.A. Jones, Robert Wood Johnson Medical School 151
Mental disorders (particularly major mood

disorders and substance abuse) are associated
with more than 90% of all cases of suicide.
Age variable: Young primary psychotic disorders
Older major depression
However, suicide results from many complex

sociocultural factors and is more likely to occur
during periods of socioeconomic, family and
individual crisis (e.g. loss of a loved one,
employment, honor).
152
Warning Signs
Talks about committing suicide
Has a suicide plan
Withdraws from friends, social activities, hobbies,
work, or school
Prepares for death by making arrangements (will
etc.)
Gives away prized possessions
Loses interest in personal appearance
Depression
Increases use of alcohol or drugs
Drastic changes in behavior
History: prior attempts, recent severe losses
153
BEHS 640
Death and Dying

Professor
154
Perceptions Differ
What do you think of
when you think about death?
How would your life be different
if you did not have to face death?
155
Death: A Mysterious Paradox

Death is the transition from the state of
being alive to the state of being dead.
Deeply personalyet universal

Happens everydayhappens only once
Liberatingor a trap
The endor the beginning
156
The final event of life

Preoccupation with the meaning of
death
Natural or unnatural
Peaceful or violent
Life after death
Spiritual beliefs
Before my time
Who will go first
Concern for those left behind
Affects us throughout life
157
Facing Death
Age Differences
If you were told that you had a terminal
illness and six months to live, how would
you want to spend your time?
158
Percent of Choices by Age Category

Activity Choice
Marked change in lifestyle,
self-related (travel, sex,
experiences)
Inner life centered (read,
pray, contemplate)
Focus concern on others
Complete projects, tie up
loose ends
No change
Other
20-39 40-59
60+
24
15
14
14
37
29
25
12
11
10
17
29
31
8
159
Age Differences: Losses caused by

death, Concerns, Comfort Level
Older persons less concerned with caring
for dependents or causing grief
Older persons more concerned with
financial burdens left
Older persons less concerned with loss of
opportunity for experiences
Older persons less frightened by death
160
Impact of religiosity on attitudes toward

death
Very Religious .
Least fear of death
Nonreligious. Moderate fear of death
Irregular WorshippersHighest fear of death
161
The Dying Process: Kubler-Ross
Based on clinical experiences with

dying patients
Five stages of dying
1.
2.
3.
4.
5.
Denial
Anger
Bargaining
Depression
Acceptance
Not invariant. Not universal

162
DENIAL
Resistance to reality
of impending death
Search for other
diagnoses or miracle
cures
Patient may withdraw
from physicians care
Facilitate further
evaluation
Leave the door open
163
Why me?
Hostility, resentment,
ANGER
envy
Any target in the
environment,
including family,
friends, medical staff,
material things, God
164
Lets make a deal
BARGAINING
Deity
Physician
Plea to extend life in

exchange for a
change in behavior
If I can live
untilthen I wont
ask for more
Ill become a better
person
165
DEPRESSION
Manifestations of
the illness become
too serious or
imposing to ignore
or deny.
Hospitalization,
surgery, imposing
symptoms
Realization of
unavoidable death
Immense sadness
166
Sense of great loss
ACCEPTANCE
Resolute about
impending death
End of struggle
Sincere
preparations can
begin
Take care of
business
Say goodbye
Prepare for
transition
Comfort others
167
Major Symptoms in Terminally

Ill Patients
Symptom
Pain
Incontinence
Confusion
Breathlessness
Nausea
Bedsores
Vomiting
Open Wounds
Incidence (%)
58
38
21
17
16
15
13
13
168
Major Needs of Dying Persons

The need to control pain
The need to maintain dignity
The need to receive love and

affection
169
How can these needs be met?

Active pain management
Patient participation in decisions that affect
treatment or outcomes
Advance Directives, e.g. Living Will
(Patient Self-Determination Act)
Holding, touching, listening, and

supporting
Facilitate continuous family involvement
170
The Dying Context

Most say that they want to die at home, but most
die in hospitals
When a loved one dies at home, family often
report positive feelings. However, the burden of
care is also felt.
Since the leading causes of death are chronic
conditions (heart disease, cancer, HIV AIDS),
there is usually a prolonged terminal phase.
children who are dying
171
Palliative Care
Providing relief from physical
symptoms and suffering
May be initiated at any point during
illness, along with disease-directed tx
Triggers for palliative consult
Increasing suffering with poor prognosis
Decreasing response to aggressive tx
Imminent death
Palliative Care Team - Interdisciplinary

172
The Hospice Movement

The primary goal of hospice is to help
people live as individuals during the weeks
and months left to them and to help them
die with as little discomfort and as much
serenity as possible.
Alleviate or prevent pain
Allay fears
Treat patient and family together
173
Hospice: A special concept of

care
Hospice is a special concept of care
designed to provide comfort and support
to patients and their families when a lifelimiting illness no longer responds to cureoriented treatments.
Hospice Foundation of America
174
Hospice is not a place.

80% of hospice care is provided in
homes and in nursing homes.
Hospitals may also incorporate
hospice care.
175
The Grieving Process

Grieving is an emotional response to
loss.
Its expression is culturally determined.
Normal bereavement period: 6-12
months
Death of child may take years
176
Stages of Grieving (Western

World)
1. Acute Disbelief: Phase of Protest
Individual not fully aware of loss
Angry at Physicians or others

May last minutes, hours, days
177
2. Grief Work: Phase of Disorganization

Emotional sense of loss
Withdrawal from social contacts
Obsessional review: Mental focus on
memories and loss of experiences.
Self Berating: If only I had
Waves of grief experienced
178
3. Resolution: Phase of Reorganization
New relationship formed with loved one
Acceptance that they and the world,

though different, are still vibrant
179
Mourning Differs with Age

Infants
Withdraw from social contact, refuse to eat
Children
Hyperactivity, cling to living parent in response
to parents perceived sadness, lack of
cognitive understanding of death, self-blame
180
Adolescents
Impulsive behaviors, substance abuse,
sexual activity, anger
Adults
Illness, substance abuse, grieving stages
Elderly
Withdrawal from social contact, high death
rate within 1 year of spousal death
181
Complicated Grief
A chronic, heightened state of mourning
Extreme focus on the loss and preoccupation
with ones sorrow
Intense longing for the deceased and
problems accepting the death
Detachment and withdrawal from social
activities
Bitterness, Irritability, Lack of Trust
Depression, deep sadness, feeling that life
holds no meaning
Inability to carry out normal routines or to
move forward with life
Risk factors for complicated grief
An unexpected or violent death

Suicide of a loved one
Lack of a support system or friendships
Traumatic childhood experiences, such
as abuse or neglect
In the case of a child's death, the number
of remaining children
Lack of resilience or adaptability to life
changes
History of depression, anxiety disorders
How does culture impact endof-life care?

Requests for non-disclosure
Mistrust due to past cross-cultural abuses,
prejudice
Different values regarding life, treatment
withdrawal, place of death, manner of death
Misunderstanding regarding rituals
Misunderstanding based on language
differences
Misunderstanding of western values by both
doctors and patients
184
Asking about end-of-life practices

Start with a Statement of Respect.
I know very little about how your culture
deals with things at such a time. I
understand and respect the fact that
different people handle things in very
different ways. I would very much
appreciate it if you would teach me what
I need to know to be of help.
Ask open ended questions about the persons
culture, rather than about the specific patient.
185
For you, death is both a personal and a

professional experience.
How will you view it?? How will you
care for the dying??
186
I am standing upon the seashore. A ship at

my side spreads her white sails to the
ocean. She is an object of beauty and
strength. I stand and watch her until at
length she hangs like a speck of white cloud
just where the sea and sky come to mingle
with each other.
Then someone at my side says: There, she
is gone!
187
Gone where?
Gone from my sight. That is all.
Her diminished size is in me, not in her.
And just at the moment when someone at
my side says, There, she is gone!, there
are other eyes watching her coming, and
other voices ready to take up the glad
shout:
Here she comes!
And that is dying.
Henry Scott Holland
188
BEHS 640
Family Violence
Professor
189
FAMILY VIOLENCE
Violence is defined as an act
carried out intentionally (or
nonaccidentally) to cause physical
pain or injury to another person.
Gelles & Cornell, 1990

190
The U.S. A Violent Country

The U.S. murder rate is, by far, the highest
in the industrialized world.
U.S.
Germany
Canada
England
0
10
Per 100,000 population
Bureau of Justice Statistics, World Factbook of Criminal Justice Systems191
Dont Families Protect Us

From Violence?
Approximately 13% of all homicides are
husband-wife killings
Approximately 28% of female homicide
victims were known to have been killed by
their husbands, former husbands or
boyfriends.
30% of married women in the U.S. are victims
of physical abuse by spouses at some point
in their marriages.
192
Domestic violence is the leading cause of

injury to women between ages 15 and 44 in
the U.S. more than car accidents,
muggings, and rapes combined.
Many women and children are actually more

likely to be assaulted in their own homes than
on the streets of U.S. cities.
The family can often be considered
the cradle of violence.
193
Family Violence: A Social

Problem
A long-standing social condition
Social Problem
194
Societal reactions are key to redefining

a social condition as a social problem.
Reactions by individuals, institutions,
media, etc.
Family violence may be condemned in some
societies and not in others.
195
Maltreatment of children
Not considered abnormal in the U.S.
until mid to late 1800s.
battered child syndrome (1962)
Child Abuse Prevention and Treatment Act
(1974)
Protection of Children Against Sexual
Exploitation Act (1978)
Child Sexual Abuse and Pornography Act
(1986)
196
Abused women
Not considered victims until the late
1800s.
First spouse abuse laws (1870s): Illegal to
beat a wife with a stick, pull her hair, choke
her, spit in her face, or kick her to the floor
Battered womens movement (1970s)
International Tribunal on Crimes Against
Women (1976 33 countries)
Violence Against Women Act (1995)
197
Other Forms of Family Violence

Date rape, marital rape, and courtship
violence became issues of concern in
the 1980s.
Elder abuse haws emerged as a social
problem in the last 10-15 years.
198
Types of Family Violence

Child Victims
Physical Child Abuse
Child Sexual Abuse
Child Neglect
Psychological Maltreatment
Adult Victims
Marital Violence/Partner Violence
Elder Abuse
199
Child Victims U.S.,2007

2.1 million referrals
ABUSE:
10.6 per 1000 children
FATALITIES:
2.04 per 100,000
Childrens Bureau, 2007
200
Child Victims Who Reports?
Childrens Bureau, 2007
Rates of Abuse, by Type

per 1000 children
8
Neglect
7.1
6
5
Other
4
3
2
1
0
Physical Abuse
2.3
Sexual
Abuse
1.2
Psych
Medical Mal
Neglect
.3
0.9
3.2
202
1. Physical Child Abuse (PCA)

Definition: Acts of violence by adults
against children.
What kinds of acts??
Some acts are clearly abusive and some
are not.
Poisoning and smothering
Fatal pepper aspiration
Intentional microwave burning
203
Case 1
Three-year old Jimmy was playing with his puppy
near a pond in his backyard. He tried to make
his puppy drink from the pond by roughly holding
his face to the water. Jimmys father saw him
forcing the puppy to drink and yelled at him to
stop. After Jimmy did not respond, his father
pulled Jimmy away from the dog and began
holding his head under water to teach him a
lesson about the appropriate way to treat his
dog.
Barnett, Miller-Perrin, Perrin, 1997 204
Case 2
Angelas baby, Maria, had colic from the day
she was born. This meant that from 4:00 in
the afternoon until 8:00 p.m. everyday, Maria
would cry inconsolably.
No matter what
Angela did, nothing would help Maria to stop
crying. One evening, after Maria had been
crying for 3 straight hours, Angela began
shaking Maria out of frustration. The shaking
caused Maria to cry more loudly, which, in
turn, caused Angela to shake the 5 month-old
more vigorously. Angela shook Maria until
she lost consciousness.
205
Barnett, Miller-Perrin, Perrin, 1997
Case 3
Ryan and his brother Matthew were playing with
their new action figures when they got into a
disagreement. Both boys began hitting each
other and calling one another names. Alice, the
mother of the boys, came running into the room
and pulled the boys apart. She then took each
boy, pulled down his trousers, put him over her
knee, and spanked him several times.
Barnett, Miller-Perrin, Perrin, 1997 206
Legal definitions vary slightly, but tend to

include these features:
1.
2.
3.
4.
Range of acts
Intentional harm
Types of injuries
Allowance for reasonable corporal
punishment by parents
Munchausen Syndrome by Proxy
207
Estimated Rates of PCA

Two methods of estimating rates:
1. Official estimates: The number of
cases of physical abuse reported to
investigatory agencies, schools,
hospitals, and other social service
agencies.
168,278 substantiated cases in 2001
208
2. Self-report estimates: Survey

responses
National Family Violence Survey (1985)
Parents reported on techniques used
over past year - 75% reported at least
one violent act
Most acts were mild (spanking or
slapping)
2% reported abusive violence (beat up,
burned, used knife or gun)
209
PCA: Characteristics of Victims

Age
Percentage of Victims Reported

by Age
100
80
60
51
40
26
23
6-11
12-17
20
0
0-5
Risk declines with age.

210
Gender
For minor acts of abuse equal risk
For major acts of abuse males at
slightly higher risk
For children under 12 males at higher
risk
For children over 12 females at higher
risk
211
Socioeconomic Status
Occurs at higher rates among
economically disadvantaged families
Serious and fatal injuries more likely

among families below poverty level
212
Other Characteristics that Increase Risk

Birth complications
low birth weight
premature birth
Disabilities
Emotional disturbance
Learning disabilities
Physical health problems
Language problems
213
Four Theoretical Models for

Explaining Physical Child Abuse
1.
Individual Pathology of the Perpetrator

Anger control problems
Depression
Low frustration tolerance
Deficits in empathy
Personality disorder
214
2. Parent-Child Relationship
Characteristics of the child
Characteristics of the adult
Lack of parenting skills
Unrealistic expectations of children
Easily stressed
Over-extended
215
3. Family Environment
Current abusive practices (marital)
Intergenerational abusive practices
Volatile family relationships
Extreme power differentials within
family
216
4. Situational and Societal Conditions

Single parent household
Situational stress (large family,
inadequate housing)
Unemployment or underemployment
Social isolation
Societal approval of violence
Societal approval of extreme power
differentials
217
Consequences of
Physical Child Abuse
Medical Problems
Bruises, especially in uncommon sites
Head injuries from blows to head or from
shaking
Retinal hemorrhage/detachment
Chest and abdominal injuries
Fractures
Burns
See Fadem, table 22-3, pg. 358
218
Psychosocial Problems
Delayed play and/or social interaction skills
Insecure attachment
Aggression and noncompliance
Substance abuse (adolescents)
Cognitive Problems
Delayed cognitive development
Verbal deficits
Poor school adjustment and performance
//
219
ABUSE??
Coining
2. Child Sexual Abuse: What is it?

Case 1
Jamie, a 15 year old, frequently babysat his
neighbor, 4 year old Naomi. Each time Jamie
baby-sat Naomi, he had her stroke his
exposed penis while they watched her favorite
video.
Case 2
Manuel and Maria frequently walked around nude at
home, in front of their 5 year old son, Ernesto.
221
Case 3
Sally was a 16 year old self-proclaimed
nymphomaniac.
Sally had numerous
boyfriends from school with whom she had
physical relationships (kissing, fondling,
sexual intercourse). One evening while Sally
was home alone with her 45 year old
stepfather, he asked her if she would like to
mess around. Sally willingly agreed to have
sexual intercourse with him.
222
Definition of Child Sexual Abuse

Elements of the Definition:
Types of behaviors
The intent involved
Age discrepancy between the offender and
the victim
Power differential between the offender and
the victim
223
Contacts or interactions between a child and

an adult when the child is being used for the
sexual stimulation of the perpetrator or
another person.
Sexual abuse may also be committed by a
person under the age of 18 when that person
is either significantly older than the victim or
when the perpetrator is in a position of power
or control over another child.
224
Intentional touching directly, or through clothing,

of the genitalia, anus, groin, breast, inner thigh,
or buttocks of another person against his or her
will, or of any person who is unable to
understand the nature or condition of the act, to
decline participation, or to communicate
unwillingness to be touched (e.g. because of
illness, disability, or the influence of alcohol or
other drugs), or due to intimidation or pressure.
225
Estimated Rates
of Child Sexual Abuse
Two methods of estimating rates:
1. Official estimates
Child Sexual Abuse tends to be underreported.

226
2. Self-report estimates: Survey responses

Approximately 20% of adult women and
between 5% and 10% of adult men in North
America have experienced some form of
sexual abuse as children.
International rates ranged from 7-36%
among adult women and 3-29% among
adult men.
Finkelhor, 1994
227
Characteristics of Victims
Age
Most vulnerable period: 7-12
Gender
Majority of CSA victims are female
Males less likely to report
228
Other Risk Factors
Presence of stepfather
Living without natural parents for extended time
Mother frequently absent from home or from
home interactions (employed, disabled, ill)
Parents with problems (marital, drugs, emotional,
isolated)
229
Who commits these acts?

Victim-Perpetrator Relationship
Females
Males
Family
29%
11%
Friend or
Acquaintanc
e
Stranger
41%
44%
21%
40%
Not Reported
9%
5%
Relationship
230
Risk Factors Associated with

Child Sexual Abuse
Within the Child
Female, prepubescent
Few close friends
Passive, quiet, trusting
Depressed affect
Needy
231
Within the Perpetrator

Antisocial tendencies
Childhood history of sexual or physical
victimization
Poor impulse control
Sensitive about performance with
women
Feelings of dependency, inadequacy
Sexually attracted to children
232
Drug abuse
Within the Family

Parents in conflict: Spouse abuse
Stepfather or without natural father
Mother disabled or ill
History of sexual abuse in mother
Unhappy family life
233
Within the Society or Culture

Sanctioning adult-child sexual relations
Neglecting childrens sexual development
Male dominated household
Oversexualization of normal emotional needs
Socializing men toward younger, smaller,
vulnerable sex partners
Child pornography
234
Effects of
Child Sexual Abuse
Physical Effects
Bruises
Genital itching, pain, bleeding, odors
Recurrent urinary tract infections
Problems walking or sitting
Stomachaches and headaches
Eating and sleeping disturbances
Enuresis
Encopresis
STDs
235
Emotional Effects
Anxiety
- Reexperiencing
Depression
- Sexual aversion
Nightmares
- Promiscuity
Fears and phobias
- Tics
Obsessions
Hostility, anger, tantrums, and aggression
Difficulty with interpersonal and intimate
//
relationships
236
3. Child Neglect
What is it?
Failure to provide basic physical health
care, supervision, nutrition, personal
hygiene, emotional nurturing, education,
and safe housing.
Severity (often assessed by degree of
harm)
Frequency and duration
237
Forms of Neglect
1. Abandonment
2. Personal Hygiene
Neglect
3. Medical Neglect
4. Nutritional Neglect
5. Neglect of Household
Safety
6. Neglect of Household
Sanitation
7. Inadequate Shelter
8. Supervisory Neglect
9. Emotional Neglect
10. Educational Neglect
11. Fostering
Delinquency
238
Estimates of Child Neglect

Official estimates
High numbers may reflect definitional problems.

239
of Child Neglect
Age
Mean age of neglected children: 6
Gender
Roughly equivalent for males and females
SES
Rates are higher in low income families
240
Consequences of Child Neglect

Physical Consequences
Most severe effect is death
Failure to Thrive Syndrome marked
retardation or cessation of growth during the
first 3 years of life
Social/Emotional Consequences
Socially withdrawn
Low self esteem
Aggression
- Interaction problems
241
//
4. Psychological Maltreatment
Subtypes
Rejecting: Verbal or symbolic acts that express
feelings of rejection toward the child
Degrading: Verbal abuse intended to degrade
Terrorizing: Actions or threats that cause extreme
fear or anxiety in a child.
Isolating: Preventing a child from engaging in
normal social activities
242
Psychological Maltreatment
Subtypes
Corrupting: Encouraging antisocial behavior

Exploiting: Using child for parents needs
Denying emotional responsiveness
Close confinement: Restricting childs
movement
243
Long term effects

Developmental effects
Higher risk for psychological disorders in

adulthood
Intergenerational Abuse - Parenting
comes naturally, but it comes naturally the
way we learned it.
Adult Victims of Family Violence

Marital/Partner Violence
Elder Abuse
245
1. Marital/Partner Violence
Categories
Verbal Aggression or Abuse
Psychological Abuse
Sexual Abuse
Mild Physical Aggression
Severe Physical Aggression
Battering (Patterned violence within
relationships characterized by fear,
oppression, and control)
246
It starts early...
100
Percentage of High School Students Who

Experienced Dating Violence,* 1999 2007
Percent
80
60
40
20
8.8
9.5
8.9
9.2
9.9
1999
2001
2003
2005
2007
0
* Hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend during the 12 months before the survey.
1 No significant change over time
National Youth Risk Behavior Surveys, 1999 2007
Estimates of
Marital/Partner Violence
1. Crime Reports
9-15% of all homicides are committed by
intimates
Women twice as likely to be killed by husbands
than the reverse
2. Self-Report Surveys
16% of married partners experienced an episode of
violence in the past year
Rates of marital violence were near equal for men
and women
248
of Marital Violence
Age Occurs most frequently between 18-30
Gender
Females more likely to be victims of homicide.

Equal rates of violence overall, but females more
likely to be victims of severe violence
SES
Battering more prevalent in low-income and
blue-collar homes.
249
Battered Women
M.D.
Agencies
In-community
In-house
250
Why is it underreported?
Sensitivity of the topic
Embarrassment to victim and perpetrator
Privacy
Acceptance of certain levels of violence

Fear of interference by agencies
Reporting may exacerbate the problem
But I love him/her
251
Why do they stay?

A battered woman is more likely to stay if:
The violence is less severe and less frequent
The woman experienced family violence as a
child
The society condones the violence
The woman has limited resources and/or
power
Commitment to the relationship
Adjustment made to the abuse: The love
aftermath
252
Battered Husbands
Little attention has been paid to this
problem
Stigma imposed by social expectations
Battered men typically suffer less severe
injuries
253
Responsibility of Physicians
The American Medical Association
(AMA) states that physicians have an
ethical obligation to identify victims of
partner violence and intervene
appropriately.
Mandatory reporting of domestic violence is now law
in some states in the U.S. (CA, CO, KY, RI, NH*).
Physicians must know the laws that pertain in their
states.
Intimate Partner Violence (IPV)- related injuries

Even if contrary to patient wishes
With patient consent only
For data collection purposes only
254
Three screening questions

1. Have you been hit, kicked, punched, or
otherwise hurt by someone within the past
year?
2. Do you feel safe in your current

relationship?
3. Is there a partner from a previous
relationship who is making you feel unsafe
now?
255
Screening Questions
Appendix 8
DIRECT VERBAL QUESTIONS
FRAMING QUESTIONS
Because violence is so common in many

peoples lives, Ive begun to ask all my
patients about it.
Im concerned that your symptoms may

have been caused by someone hurting
you.
I dont know if this is a problem for you, but

many of the women I see as patients are
dealing with abusive relationships. Some are
too afraid or uncomfortable to bring it up
themselves, so Ive started asking about it
routinely.
Does your partner ever try to hurt you?
Do you feel unsafe at home?
Are you in a relationship with a person

who physically hurts or threatens you?
Did someone cause these injuries? Was

it your partner/husband?
Has your partner or ex-partner ever hit

you or physically hurt you? Has he ever
threatened to hurt you or someone close
to you?
Do you feel controlled or isolated by your

partner?
Do you ever feel afraid of your partner?

Do you feel you are in danger? Is it safe
for you to go home?
Has your partner ever forced you to have

sex when you didnt want to? Has your
partner ever refused to practice safe sex?
256
Use Your RADAR

R Routinely screen
A Ask questions
D Document findings
A Assess safety
R Review and refer
CDCP
Initial diagnosis: Battered Syndrome

(International Classification of Diseases: Clinical
Modification, ninth revision)
Treat for physical injuries. Be alert to

possible severe depression.
If abuse is suspected, interview the
patient alone. Provide resource
information. Refer to a safe haven, if
needed.
258
2. Elder Abuse
Destructive behavior directed toward an
older adult
occurring within the context of a relationship
connoting trust
of sufficient intensity or frequency to produce
harmful effects of unnecessary suffering,
injury, pain, loss, and/or violation of human
rights and poorer life quality.
259
Two Types
Elder Abuse
Aggressive or invasive behavior/actions or threats
of same, inflicted on an older adult and resulting in
harmful effects for the older adult.
Elder Neglect
The failure of a responsible party to act so as to
provide adequate and reasonable assistance to
meet the older adults basic needs, resulting in
harmful effects for the older adult.
260
What kinds of harmful effects?

1. Physical: Physical force is used to
inflict the abuse or physical assistance
is not provided, resulting in neglect.
2. Psychological: Verbal force is used to
inflict the abuse, or psychological or
emotional assistance is not provided,
resulting in neglect.
261
3. Social: Actions that prevent the basic

social needs of the older adult from
being met, or failure to provide
adequately for the older adults basic
social needs.
4. Financial: Theft or misuse of an older
adults funds or property, or failure to
provide for an older adults basic
material needs.
See Fadem, table 22-3, pg. 358)
262
How many elders are abused?

Estimates are difficult to obtain.
Elders not always able to report.

Reporting might exacerbate the problem.
Elders often have multiple problems.
Powerlessness - No where to go.
The best estimate revealed that

approximately 1 million (3.2%) of U.S. elders
are abused each year.
263
Characteristics of the Abusers

Two-thirds of suspected abusers were
family members
Spouses
Adult Offspring
Other relatives
Financial problems
Low levels of social support
264
Whos responsible for the care of

our elders?
Issues
Family mobility
Childless elders
Changes in traditional roles
Who can be held accountable?
Whos watching?
Assessment Interview
for Health Care Providers
Questions developed by LA County

Medical Association et.al.
1. Has anyone at home ever hurt you?
2. Has anyone ever touched you when you
didnt want to be touched?
3. Are you afraid of anyone?
4. Has anyone ever threatened you?
5. Has anyone ever failed to help you take
care of yourself when you needed to?
Victim Services, New York and Mt. Sinai, 1988
266
Issues in Family Violence
Sibling abuse
Parent abuse
Incest
Children who kill parents Parricide
Parents who kill children Infanticide,
Murder
The family can often be considered
the cradle of violence.
267
BEHS 640
Culture and Medicine

Professor
268
Why do I need to know?

The range of cultural backgrounds that MDs may
encounter are countless.
Your patients trust that you will treat them with cultural
respect.
Without understanding the importance of culture, MDs run
the risk of limiting their effectiveness in treating patients.
Cultural competency training is required as a condition of
licensure in many states.
AND, in case you didnt know
Its a requirement for entry into the SGU Clinical Program!

269
American Medical Association:

Cultural Competence Initiative, 1999
As physicians, our first concern is always our
patients, especially the most vulnerable of those who rely
on our care. Todays changing and increasingly diverse
society, however, makes it clear that virtually every
group has its own vulnerabilities and its own special
needs.
Unfortunately, for most of us, our traditional training
in medical school offers little guidance in how to treat
individuals influenced by cultures of different groups with
which they identify.
Getting to the heart of these differences, and learning
responsible ways to address them in accord with our
ethical values as physicians, is what the initiative is all
about. (President, AMA)
270
From the AMA Website

They have the same medical condition.
They may not receive the same medical
care.
At a time when many consider race or ethnicity to be

irrelevant to modern health care, the results of the recent
Institute of Medicine report on health care disparities are
a wake-up call.
This report indicates that racial and ethnic minorities tend
to receive lower quality health care, even when accessrelated factors, such as patients income or insurance
status, are controlled.
This report indicates that the sources of these disparities are
complex, but it is clear that physicians need to take a
leading role in protecting the health of all Americans.
(Message from President, AMA)
271
Institute of Medicine Report,

2002
UNEQUAL TREATMENT: Confronting

Racial and Ethnic Disparities in Health
Care
272
Disparities in the Clinical Encounter:

The Core Paradox
How could well-meaning and highly educated
health professionals, working in their usual
circumstances with diverse populations of
patients, create a pattern of care that
appears to be discriminatory?
273
Disparities in the Clinical Encounter:

The Core Paradox
Possibilities examined: bias (prejudice), uncertainty,
stereotyping
Bias no evidence suggests that providers are more
likely than the general public to express biases, but
some evidence suggests that unconscious biases
may exist
Uncertainty a plausible hypothesis, particularly
when providers treat patients that are dissimilar in
cultural or linguistic background
Stereotyping evidence suggests that physicians,

like everyone else, use these cognitive shortcuts
274
What is Culture?
AMA Cultural Competence Compendium
Any group of people who share experiences,
language, and values that permit them to
communicate knowledge not shared by those
outside the culture.
275
What is Culture?
A set of shared guidelines, ideas, and
beliefs (both explicit and implicit) which
individuals inherit as members of a
particular group that direct them on:
How to view the world
How to experience it emotionally
How to behave in it in relation to other people,
supernatural forces, and the natural
environment
Helman, 1998
276
Culture also provides individuals with a

way of transmitting these guidelines,
ideas, and beliefs to the next generation
by way of symbols, language, art, and
ritual.
Culture helps us define our Identity
277
As long as we are within our own

cultural group
We feel comfortable
Things are predictable
Communication is easy
Expectations are known
Culture is protective and promoting.
Culture is often invisible.
278
When people from different cultures

meet..
Our cultures might become more apparent
Culture is what makes you a stranger when youre

away from home.
279
Food
Dance
Games
Arts
Music
Holidays
Dress
Etiquette
Surface Culture
Ceremonies
Rituals
Knowing
Social Structure
Spiritual Beliefs
Values
Deep Culture
Language
History
World View
Healing
280
Cultural Consciousness
We must become aware of our own cultural
beliefs, attitudes, behaviors, ideas, etc.
We must always remember

that we view the world
through our own cultural
lens.
281
Body Ritual among the Nacirema

Anthropological Study
Nation originated by culture hero,
Notgnihsaw
Ritual Activity focuses on the body
Fundamental belief that body is ugly and
disease-susceptible
282
Each household has 1 or more shrines

The ceremonies are private
Focal point of shrine box or chest
containing charms and potions
Medicine Men
Herbalists
Beneath the charm box font

Mouth rite
283
In what area of the world do you think

the Nacirema live?
What words best describe their culture?
284
Cultural Misinterpretations
Sometimes culture leads to prejudice
No one is born prejudiced, racist, sexist
Our attitudes are shaped by information
received from our family, school, church,
community, society
Since culture is often invisible, we may

not be aware of our own prejudices.
285
Cultural Errors that May Lead to Conflict

1. Overgeneralization
Individual variation exists within
cultures.
Cultural descriptions will not apply to
each individual within a culture.
286
The Changing Demographics of the US

250
Projected U.S. Population Growth: 2000 - 2050

White*
200
150
Hispanic
100
Black*
50
API*
AIEA*
2000
2010
2020
2030
2040
2050
* Excludes people of Hispanic origin
287
Official Race Classifications

White
Persons who indicated their race as White
Entries, such as
Canadian
German
Italian
Lebanese
Near Easterner
Arab
Polish
288
Black
Persons who indicated their race as Black or
Negro
Entries, such as
African American
Afro-American
Black Puerto Rican
Jamaican
West Indian
Haitian
289
American Indian
Name of an Indian
tribe
Canadian Indian
French-American
Indian
Spanish-American
Indian
Eskimo
Arctic Slope
Inupiat
Yupik
Aleut
Egegik
Alutiiq
Pribilovian
290
Pacific Islander
Hawaiian
Samoan
Guamanian
Other Pacific Islander
Carolinian
Fijan
Tokelauan
Palauan
Kosraean
Tongan
Melanesian
Yapese
Tahitian
Trukese (Chuukese)
Polynesian
Micronesian
Tarawa Islander
Northern Mariana
Islander
Papua New Guinean
Ponapean (Pohnneian)
Solomon Islander
291
Asian
Chinese
Filipino
Japanese
Asian Indian
Korean
Vietnamese
Cambodian
Hmong
Laotian
Thai
Other Asian
Borneo
Burmese
Bangladeshi
Ceram
Bhutanese
Celebesian
Malayan
Maldivian
Nepali
Okinawan
Indochinese
Indonesian
Iwo-Jiman
Javanese
Pakistani
Sri Lankan
Singaporean
Sumatran
Sikkim
292
Between 1990 and 2000, the Hispanic

population increased by 58% to 32.8
million persons.
Between 1990 and 2000, the Asian/Pacific

Islander population increased by 48% to
10.2 million persons.
293
The Melting Pot
Multicultural Stew
294
Cultural Errors that May Lead to

Conflict
2. Ethnocentrism
The tendency to assume that ones own
way of life (culture) is superior to the culture
of others.
Our Way
Their Way
Cultural differences are evaluated judged

295
Cultural background influences many

aspects of life
Beliefs and values
Behaviors, perceptions, emotions
Communication, religion, the role of spirit
Family structure
Diet, dress, body image
Concept of space and time
Attitudes and practices regarding illness,
pain, and healing
296
Other influencers include

Educational factors
Socioeconomic factors (poverty)
Political factors (apartheid, racism)
Individual factors (personality, experiences)
297
The Relationship between

Culture and Health
298
Culture Defines Normality,

Disease, Illness and Health
Different concepts of wellness, normality,

and beauty
Different ideas about anatomy and
physiology
Different ideas about etiology and
treatment
299
Health Beliefs and Practices
All societies have ethnomedical systems

that address disease and death
These systems include 3 elements
1. A theory of etiology of illness
2. Techniques for diagnosing illness
3. Methods for appropriate therapy
300
Individuals ideas about health, illness, and

healing emerge from cultures
What persons define as illness
What they believe caused the sickness
What treatments they believe are indicated
What course they expect the illness to follow
301
Cultural Variations in Body Image &

Self
Beliefs about optimal body shape and size
Liposuction and dieting in Western cultures
Fatting houses in West African cultures
Beliefs about the bodys boundaries and the

sense of self
Individualism in Western cultures
Group identity in Eastern and African cultures
302
Cultural Variations in Etiology and

Treatment
Beliefs about the bodys inner structure
and functioning
Influence peoples perceptions and
presentations of bodily complaints
Influence peoples responses to medical
treatment
303
Case History: The Clean Out
Upon visiting a traditional healer in

South America, a preventive
procedure was prescribed:
1. An enema to clean out the bowels
2. An induced vomit to clean out the
stomach
3. A sneeze (induced by snorting a pepper
mixture) to clean out the head
The procedure is done routinely to

prevent illness.
304
Hot-Cold Theory of Disease

(Latin America, Morocco)
To maintain health, the bodys internal balance
must be maintained between the opposing
powers of hot and cold.
Hot and cold do not pertain to actual
temperature, but to a symbolic power contained
in most substances.
In illness, health is restored by re-establishing
the internal balance by exposing ones self to, or
ingesting, items of the opposite quality to that
believed to be responsible for the illness.
305
Based on the Hot-Cold Theory of

Disease, both pregnancy and
menstruation are considered to be hot
states, and are treated by the ingestion
of cold foods and medicines. Women
may avoid certain foods which they
classify as hot to prevent clotting of
menstrual blood or blood of birth. This
may exacerbate vitamin deficiencies.
306
Beliefs about Blood

Volume
High blood due to too much blood
Consistency
Thin blood causing anemia
Temperature
Hot illnesses caused by heat in the blood
Quality
Impurities in the blood from constipation or
menstruation
Polluting power
Men are weakened in the presence of
menstrual blood
307
Case history: Loss of Blood

A 25 year old Vietnamese woman was seen for a
routine prenatal examination. As part of her
evaluation, she had blood drawn for laboratory
testing. Within the next few days, she returned
with a variety of symptoms, including weakness,
fatigue, and coryza. She attributed this to having
blood removed, feeling that removal of blood
weakens the system and can cause illness.
Interruption of cycle: food-----blood-----jing-----chi-----shen

308
Case history: High Blood

Among black and low-income families in
southern U.S., the use of the illness label high
blood is common.
Low blood is associated with weakness and
fatigue and is traditionally treated by eating
red foods, such as beets.
High blood is associated with an excessive
intake of rich food and is treated by taking
lemon juice, vinegar, and bitters.
Patients who confuse high blood pressure with high
blood may respond by increasing their salt intake.
309
Case history: Sleeping Blood

A 48 year old woman from the Cape Verde
Islands was admitted to a neurology ward in the
U.S. She was suffering from paralysis,
numbness, pain and tremor of her right arm.
Two years earlier, she had suffered bilateral
fractures of her wrists. After this, the symptoms
began to gradually appear.
No physical cause for her illness could be

found.
310
Case history: Sleeping Blood

It was discovered that she believed herself to be
suffering from sleeping blood (sangre dormida).
In this illness, traumatic injuries can cause a
persons normal blood to leak out into the skin,
turn black (i.e. cause a haematoma), and become
sleeping blood. If the sleeping blood is not
removed, it can cause obstructions leading to
strokes, blindness, and heart attacks.
She was treated by removing 12 ml of blood from
her right wrist on 2 occasions, followed by cold
packs. Her tremor, pain, and paralysis completely
disappeared.
311
Health care programs must be designed

not only to address medical concerns, but
must be planned in collaboration with the
cultural community to be served.
Oral Rehydration Therapy is a safe and
inexpensive way to prevent and treat the lifethreatening dehydration associated with
diarrhea in both infants and children.
312
Case History: Oral Rehydration Therapy

in Pakistan
Despite mass campaigns and the free provision of
ORT through local clinics, it was NOT being
used by mothers in rural areas of Pakistan.
WHY?
1. Diarrhea is very common, and many mothers
saw it as a natural part of teething and
growing up.
313
2. Some believed it is dangerous to stop

diarrhea, because diarrhea removes heat
from the body and so helps to reduce fever.
3. Some believed that diarrhea was caused by
nazar (evil eye) or sutt (fallen fontanel), and
thus required traditional remedies.
314
4. Some mothers saw diarrhea as a hot

illness requiring a cold treatment. Western
medicines are also hot.
Bringing children for Oral Rehydration Therapy

was NOT CONSISTENT with these mothers
definition of illness, their understanding of the
etiology or function of diarrhea or how it should
be treated.
Mulls, 1988
315
The Spirit Catches You

and You Fall Down
Language
Health Practices (birth,
records)
Health Beliefs
(causation, tx)
316
Cultures provide different ways of

expressing illness and problems.
Culture-bound syndromes provide extreme
examples of these culturally specific
expressions.
317
Culture-Bound Syndromes
Clusters of symptoms, signs, and
behavioral changes, the presentation of
which is unique to a particular culture.
Members of the culture recognize the
syndrome and respond to it in a
standardized way.
318
Culture-Bound Syndromes
The conditions often have symbolic meaning
moral, social, or psychological to the victim
and to those around him or her.
The condition often links an individual case of
illness with wider concerns, including his/her
relationship with the community, supernatural
forces, and/or the environment.
319
Examples of Culture-Bound
Syndromes
1. Amok
Malaysia, Laos, Philippines, Papua New
Guinea, Puerto Rico
Symptoms
Brooding, followed by intense,
hyperactive or violent behavior,
persecutory ideas, amnesia, and
exhaustion.
Usually among men
320
Syndromes
2. Ataque de Nervios
Latin America
Symptoms
Uncontrollable shouting, crying,
trembling, feelings of heat in the chest
rising to the head, numbness,
aggressive behavior, seizures, fainting
Gradual build-up, followed by acute
onset of symptoms, then attack
precipitated by stressful event
321
Syndromes
3. Koro
India, Singapore, Malaysia, China,
Thailand (also cases in U.S. and Nigeria)
Symptoms
Sudden and intense anxiety that the
penis is shrinking and will recede into
the abdomen and cause death
322
Syndromes
4. Susto
Mexico, Central and South America*
Belief that individual is composed of physical
body and one or more immaterial souls that
my become detached and wander
Symptoms
Follows an unsettling event or disturbance of
nature by the victim
Appetite and sleep disturbances, listlessness,
depression, lack of interest in self
Sufferers believe that their soul has left their body.
*Also in Southeast Asia different names
323
Syndromes
5. Taijin Kyofusho
Japan
Symptoms
Intense fear that ones body
displeases, embarrasses, or is
offensive to others.
324
Syndromes
6.
Anorexia Nervosa
Symptoms
Intense anxiety and pathological
misperception about ones body image
Person engages in extreme, selfdestructive behaviors to change ones
body, including self-starvation
Can result in serious illness or death
325
Syndromes
Pre-Menstrual Syndrome
Agoraphobia
326
If culture is ignored, normal behavior may

be labeled abnormal.
If culture is overemphasized, underlying
psychopathology may be overlooked.
327
Healing Models
Practitioners
Diagnosis
Etiology
Treatment
Patient Behavior
Patient priority and
role
Family priority and

role
Societal priority and
role
Prognosis
Premature Death
Goal
Function of institution
328
Cultural Insight and Cultural Humility

are Needed
Clinicians need to be aware of:
The influence of culture on the
appropriateness of certain signs, diagnostic
categories, and treatment regimens.
How people who share the patients cultural
background view the patients behavior.
Their own limitations.
329
The Explanatory Model of Illness

The explanatory model is an individuals
personal interpretation of disease.
Open communication, beginning with the
patients explanatory model, fosters
mutual respect and is the key to cultural
insight.
330
Questions for Eliciting a Patients

Explanatory Model of Illness
(Kleinman)
1. What do you think has caused your
problem?
2. Why do you think it started when it did?
3. What do you think your sickness does to
you? How does it work?
4. How bad do you think your illness is? Do
you think it will last a long time, or will it be
better soon, in your opinion?
331
Questions for Eliciting a Patients

Explanatory Model of Illness
5. What kind of treatment would you like
to have?
6. What are the most important results
you hope to get from treatment?
7. What are the chief problems your
illness has caused you?
8. What do you fear most about your
sickness?
Kleinman et.al., 1978
332
The ETHNIC Model

E:
Explanation
What do you think may be the reasons you
have
these symptoms?
What do family, friends, and others say
about them?
Do you know anyone else who has or has
had these symptoms?
Levin, Like, Gottlieb

Department of Family Medicine
UMDNJ Robert Wood Johnson Medical School, 2001
333
The ETHNIC Model

T:
Treatment
What kinds of medicines, home remedies
or other treatments have you tried?
Is there anything you eat, drink, or do (or
avoid) on a regular basis to stay healthy?
Tell me about it.
What kind of treatment are you seeking
from me?
334
The ETHNIC Model

H:
Healers
Have you sought any advice from
alternative or folk healers, friends or other
people who are not doctors for help with
your problems? Tell me about it.
335
The ETHNIC Model

N:
Negotiate
Negotiate options that will be mutually acceptable to you
and your patient and that do not contradict, but rather
incorporate your patients beliefs.
I:
Intervention
Determine interventions with your patient. May include
healers as well as other cultural practices (e.g. food
eaten or avoided in general and when sick)
C:
Collaboration
Collaborate with the patient, family members, other
health care team members, healers and community
resources.
336
The LEARN Model of Cross-Cultural

Communication
LListen to the patients perception of the
problem
EExplain your perceptions of the problem

AAcknowledge and discuss differences
and similarities
RRecommend treatment
NNegotiate an agreement
Berlin & Fowkes, 1983
337
The FIFE Interview
F = Feelings
I = Ideas
F = Functioning
E = Expectations
Stewart, M, et al; Rosenberg, EE, et al; EPERC
338
F = FEELINGS related to the illness,

especially fears
What are you most concerned about?
Do you have any specific fears or worries
right now?
I imagine you have had many different
feelings as you have coped with this illness.
Sometimes people have fears that they keep
to themselves and dont tell their doctor.
339
I = IDEAS and explanations of the cause

What do you think might be going on?
What do you think this pain means?
Do you have ideas about what might have
caused this illness?
340
F = FUNCTIONING, the illnesss

impact on daily life
How has your illness affected you day
to day?
What have you had to give up because of your
illness?
What goals do you have now in your life? How
has your illness affected your goals?
How does this illness affect important people in
your life?
341
E = EXPECTATIONS of the doctor & the

illness
What do you expect or hope I can do for you
today?
Do you have expectations about how doctors
can help?
What do you hope this treatment will do for
you?
What are your expectations about what might
happen with this illness?
342
National Standards for Culturally and

Linguistically Appropriate Services in
Health Care (US DHHS, OMH, Dec. 2000)
Recommended
Mandated (Language Assistance)
343
National Standards for Culturally and

Linguistically Appropriate Services in Health
Care (US DHHS, OMH, Dec. 2000)
Recommendations
1. Health Care Organizations should ensure
that patients/consumers receive from all
staff members effective, understandable,
and respectful care that is provided in a
manner compatible with their cultural health
beliefs and practices and preferred
language.
344
Recommendations
2. Health Care Organizations should
implement strategies to recruit, retain, and
promote at all levels of the organization a
diverse staff and leadership that are
representative of the demographic
characteristics of the service area.
345
Recommendations
3. Health Care Organizations should ensure
that staff at all levels and across all
disciplines receive ongoing education and
training in culturally and linguistically
appropriate service delivery.
346
Mandates
4. Health Care Organizations must offer and
provide language assistance services,
including bilingual staff and interpreter
services, at NO COST to each
patient/consumer with limited English
proficiency at all points of contact, in a
timely manner during all hours of operation.
347
Mandates
5. Health Care Organizations must provide to
patients/consumers in their preferred
language both verbal offers and written
notices informing them of their right to
receive language assistance.
6. Health Care Organizations must assure the
competence of language assistance
provided to LEP patients/consumers.
Family and friends should not be used to
provide interpretation services (except on
the request of the patient/consumer).
348
Mandates
7. Health Care Organizations must make
available easily understood patient-related
materials and post signage in the languages
of the commonly-encountered groups
and/or groups represented in the service
area.
349
Standards 8-14: Organizational

Supports
8. Strategic Plan
9. Organizational Self-Assessments
10. Data Collection and Management
11. Community Profile and Needs Assessment
12. Community Partnerships
13. Conflict Resolution and Prevention
14. Public Reporting of Progress
350
Culturally Competent Care

Health care that is sensitive to the needs
and health status of different population
groups. It considers
Demographics
Culture incl. Health Beliefs and Behaviors
Language (Use of medical interpreter)
Risk Factors
Major Diseases
351
Culturally Competent Care

Requires that you first become aware of
your own cultural lens.
Requires that you respect other cultures,
even when you dont understand them.
Requires that you seek to understand the
cultures of those for whom you provide
care.
352
www.amsa.org/programs/gpit/cultural.cfm
www.ama-assn.org/ama/pub/category/4848.html
www.omhrc.gov/clas/finalcultural1a.htm
www.ethnomed.org
www.webofculture.com
353

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BEHS 640

Why do you need to know?

To recognize age appropriate behaviors

Each week, for children 1-3 years of

the night are not unusual.

2. Carol just doesnt seem to know how to play

<18 mos of age

Aspects of Human Development

Many Disciplines Contribute to an

Three Major Issues

II. Continuity vs Stages

III. Stability vs Change

John Locke (End 17th century)

Jean Jacques Rousseau (Mid 18th century)

Man is born free, yet we see him everywhere in chains.

John B. Watson and B.F. Skinner: Human nature is

Give me a dozen healthy infants, well-formed, and

Richard J. Herrnstein & Charles Murray:

There are substantial individual and group differences in

The Bell Curve: Intelligence and Class Structure in

Nature and nurture interact.

Development is shaped by genetic

Is development a gradual continuous

What about critical periods - crucial

Maturational aspects of development are

Stage theorists posit that development occurs in

Interplay of maturation with stage attainment

When the Bough Breaks

Infancy and Toddlerhood

The Competent Newborn

Moro (startle) Reflex

The Newborn: Sensitive to the

Which will be more attractive?

Babies less than 2 months of age spend more time

Milestones for Child Development

General Guidelines for

Fine Motor Adaptive

Denver II: The Age Line

Denver II: Interpreting Items

Each item is represented by a bar.

Bar shows the age at which 25%, 50%, 75%, and

CHEST UPARM SUPPORT

Excerpt from Denver II

Developmental Red Flags

Abnormal or absent primitive reflexes at

Persistent fisting at 3 months: neuromotor

Failure to reach for objects at 6 months:

Absent smile at 3 months: visual loss,

Absent babbling at 6 months: hearing deficit

Developmental Red Flags

Persistent mouthing of objects at 12

Advanced non-communicative speech (e.g.

Regression from any previously acquired

Lack of normal developmental progression

Conditions Associated with

Cloth and Wire Surrogate Mothers

Not exclusively associated with feeding,

Temperament - Nine Relatively

Normal Responses to SEPARATION

2. Insecurely Attached: Anxious

3. Insecurely Attached: Anxious

4. Insecurely Attached: Disorganized

What are the possible effects of