In this article in the International Journal of Drug Policy, Stanton details the story of American "social hygiene" films - movies shown to teenagers to make them into better people. Including their treatment of drugs and alcohol, these films describe a well-meaning American moralism that is both bereft of reality and, at the same time, stultifies genuine thinking about social problems and their causes.

Prepublication version of article appearing in the International Journal of Drug Policy, 11:245-250, 2000.
© Copyright 2000 Stanton Peele. All rights reserved.

Review of Mental Hygiene: Classroom Films - 1945-1970, by Ken Smith, Blast Books, NY 1999

Ken Smith was working for The Comedy Channel, excerpting industrial and classroom films for programming laughs, when he became addicted to what he terms "hygiene" movies. These were a few thousand short subjects - 10 minutes in length and called "social guidance" films - created by a small number of specialty studios (mainly in the Midwest) for classroom viewing. Their topics were driving, dating, sex, drugs, hygiene, and - generally - getting along in life and with others. As he screened the films for humorous moments, Smith became aware that they shared distinctive themes and techniques. Smith came to see the genre as "a uniquely American experiment in social engineering." Although today we find the themes ultraconservative, in fact the filmmakers represented a liberal-thinking progressive streak of American striving for self-betterment.

Begun after World War II - when young people, freed from the depression and the War, were creating their own culture - the films educated adolescents about "correct" behavior, including good grooming, manners, and citizenship. The films grew from war time "attitude-building" works (some produced by leading Hollywood directors) meant to inspire both military personnel and those on the home front. For young people in the late 1940s and the 1950s, the chief message was to fit in. The films disdained independence and bohemianism, or looking or acting different in any way. That someone might simply not fit the mold of well-groomed, attractive adolescent (not to mention that someone would reject this image!) was simply not conceivable. Teens who were not able to fit in were portrayed as frankly deviant and deeply troubled, often ending up in tears or worse.

With boys, the message was to avoid delinquency and impulsive and dangerous behavior, to practice good manners, and to achieve. For girls, the message was to get a man; films told teenage girls to downplay their intelligence and independent thinking in order to curry dates and eventual marriage. Today, The Way to a Man's Heart (1945) and More Dates for Kay (1952) would be shown as object examples of the oppression of women. But, while the girl in More Dates for Kay throws herself at every man she meets, she was of course not to let her desperation push her into offering sexual favors. The 1947 Coronet film, Are You Popular, made clear "Girls who park in cars are not really popular." Thus, the industry periodical Educational Screen recommended More Dates along with How to Say No and Shy Guy for church youth meetings.

Progressing from the late 1940s through the 1950s and into the 1960s, the films encountered a difficult social reality as they encouraged conformity. As Smith describes this paradox in terms of the film Shy Guy (1947) - which featured a young Dick York, who went on to television fame as the straight-edged husband and foil in Bewitched - "what makes school kids popular with each other is often not what makes school kids popular with moms and dads." In the film, a dad who very much resembles the father in the TV series Leave It to Beaver helps his nerdy son to fit in. After the York character gains popularity by fixing the gang's record player, the narrator intones, "He's not really different."

Smith points out that conformity was encouraged as a political and social tranquilizer at a time when segregation was still law in many states. Today many could question the goal expressed in Manners at School (1956), "If we mind our own business, people will like us better." A number of films explored democracy, including a few red scare films. The most famous of these, Duck and Cover (which described how to avoid nuclear holocaust by ducking under school desks and covering up with whatever is convenient - including newspapers and blankets) achieved a second life in the 1982 documentary, The Atomic Café. Duck and Cover (which was produced on contract for the Federal Civil Defense Administration in 1951) portrayed scenes of everyday life being interrupted by blinding flashes and atomic mushrooms. Even if young viewers were unaware of radioactive fallout and the scorching heat that slaughtered those near ground zero at Hiroshima, the film seemed more likely to produce nightmares than to reassure.

While many of the films were unremittingly upbeat, a strong sadistic streak pervades others. That is, suspecting young people of the worst, the films warn of dire consequences for those who step out of line. Perhaps the strangest example of a scare film is the hard-to-catalogue What's on Your Mind, produced for the National Film Board of Canada in 1946. Smith summarizes the film's content:

"This man is a catatonic schizophrenic," says the film's bombastic narrator, Lorne Greene, as an obviously staged scene shows a guy in black leotards, his eyes turned upwards, wondering around a tile-lined room. "In a world changing overnight, men long to escape the fear of atomic destruction, of everyday living!"

In rapid succession the film cuts to a car running over a pedestrian, a distraught family waiting in line for postwar housing, a riot between union strikers and police, and a woman throwing herself off a bridge. "For some the urge to escape grows so extreme, they make the final exit."

This film had no obvious purpose or resolution - it seems mainly a tribute to uncontrolled paranoia, if not by viewers, then by the film's producers. Indeed, a number of films just warned children about environmental dangers - some of which seem quite farfetched. Their titles are indicative: Let's Play Safe (1947), Why Take Chances? (1952), and Safe Living at School (1948). The latter film emphasizes the necessity that drinking fountains have "no sharp parts" and "are safely constructed to reduce the danger of bumping your teeth while drinking." And how many women die from falls from a kitchen chair, as described in Doorway to Death (1949)?

But most scare films clearly depicted the observed catastrophes as the direct results of misbehavior. One whole subgenre of this kind of film is the highway safety film (within this subgenre were an entire group of drunk-driving films). Indeed, such films are still produced and screened in driver education classes (I saw one when, a bit past my teenage years, I accumulated too many points on my driver's license). Whereas these films had something of an educational bent previously, the advent of large-scale teenage driving by the 1950s hyped up the genre, which could now more accurately be labeled "highway accident" films. The first of these was evocatively titled, Last Date (1950), and contained the haunting line, "My face, my face!" The film was promoted with the teaser, "What is Teen-a-cide?"

In 1958, the genre transmogrified into highway gore, when Safety or Slaughter (1958 - perhaps readers at this point think Smith is making these titles up) showed actual highway carnage: "That man is a statistic. So is that girl." Some classics in this mode were Mechanized Death (1961), which opened with a dying woman hacking up blood as troopers pried her from a wreck, and Highways of Agony (1969), which first artfully showed a desolate shoe before focussing on dead bodies on asphalt. Just as great films are remade or updated over the years, The Last Prom appeared in 1972, and a staged shot of an attractive young woman in a prom dress screaming behind breaking glass is mixed with shots of bleeding bodies of girls. Highway police loved these films (which is why I got to see one as an adult), and began carrying cameras to contribute footage to the filmmakers.

Pain and death were the result of wild teen driving, and of much else that adolescents might be tempted to do. Among the categories of cautionary tales were those about sex. Post-War parents assumed that children, given freedom and independence, would constantly be tempted by sex. As Smith admits, "These were not irrational concerns." The first line of defense was to avoid sex, or to avoid getting seriously involved. Thus, films entitled Are You Ready for Marriage? (1950) and Worth Waiting For (1962) emphasized the heavy burden of the ultimate commitment. Some films emphasized the shame and social opprobrium of pregnancy. But sex education films seemed especially preoccupied with syphilis and - in the shock style that evolved - lesions, microscopic shots of bacteria, and deformed babies became staples in sixties films. Dance, Little Children (1961), made by the Kansas State Board of Health, showed syphilis as the sequelae for an adolescent girl who innocently enough wanted to go to a dance.

The extremity of these films seems to be testimony to their ineffectiveness - it was as though the ante had to be upped since children were disregarding them. Smith correlates this with the emergent rebelliousness of the 1960s. The man best positioned to capture this mood - and the recipient of Smith's vote for the archetypal social guidance filmmaker - was Sid Davis, who began his career as a stand-in for John Wayne. Davis got funding for his first film from Wayne - Dangerous Stranger (1950), a film based on a favorite topic of Davis's, child molesting. Davis returned to this topic repeatedly in his 150+ film career, claiming his own daughter made him sensitive to the issue (Davis's daughter appeared in a number of his films). Davis combined a rock solid commitment to mainstream values with an unflinching willingness to explore the dark side. Thus, Davis made Boys Beware (1961), the only social hygiene film to feature the topic of homosexuals who pick up and seduce adolescent boys: "What Jimmy didn't know was that Ralph was sick. A sickness that was not visible like smallpox, but no less dangerous and contagious. You see, Ralph was a homosexual."

Davis brings out Smith's best writing, as in his description of The Dropout (1962), the story of a boy, Robert, who doesn't feel he needs to complete high school:

The Dropout is Sid Davis at his most relentless. . . . Like teenagers in many Sid Davis teen films, Robert has made a fatal error - he thinks he can Break the Rules. This film will serve as his river of destiny, carrying him irrevocably downstream to his doom. . . . Robert, not yet realizing that he's trapped in a Sid Davis universe, visits an unemployment agency. . . . The film ends as Robert apathetically watches one of his new buddies being dragged out of a pool hall by the police. . . . [followed by] Zoom in on the eight ball. Fade to black.

Davis's films, while intense, suffered from poor production values, as Davis skimped on costs (particularly actors' salaries), and tried to cram too many themes into the ten-minute format. Frequently, the narrator in his films worked overtime breathlessly "enunciating every self-satisfied condemnation."

Of course, the story of the descent into perdition favored by Davis and other of his compatriots in mental hygiene films is the temperance tale. Alcohol, aside from drinking-driving films, was not actually a much featured topic - since, through the time the films were made, alcohol was well accepted in the U.S. (Betty Ford had not yet come forward, leading to the boom in alcoholism treatment and, eventually, a new temperance signaled by a decline in alcohol consumption beginning in 1980.) Davis did produce Alcohol is Dynamite (1967), a reminder of the "fatal glass of beer" straight from the nineteenth century. Two boys, trying to buy some alcohol, encounter a sports writer who instead tells them about three other boys who began drinking. Although in the flashback the drinkers immediately double up in pain and become zombies after their first swig, they resume drinking as soon as they regain consciousness. The narrator of their fates tells how one of the boys ended up on skid row, the other joined Alcoholics Anonymous, and the third vowed never to drink again - which he didn't. "How do I know?" the narrator asks rhetorically. It turns out that boy was his son.

Nothing shows better that mental hygiene films were not educational efforts, but moral fables, than educational movies on drugs. However, like films about menstruation, the principal producers refused to touch the topic, leaving production to independents who specialized in drug films. The earliest of these films, Drug Addiction (1951), showed the results for Marty of smoking marijuana. Stoned, he drinks from a broken Pepsi bottle and cuts his mouth to ribbons. Directly after smoking marijuana, Marty buys heroin from a local drug dealer, and proceeds straight downhill. Marty then enters a countrified rehab center where he farms and plays baseball, and soon recovers.

The focus on heroin was typical of these early films - drug use was not common among young Americans, and the idea proposed was that any drug use led virtually instantaneously to heroin addiction. Young people progressed from marijuana, to heroin, and to sobriety in a matter of weeks in The Terrible Truth and H: The Story of a Teen-Age Drug Addict (both made in 1951). Urban-centered films such as Narcotics (1951) and Monkey on the Back (1955) were among the few mental hygiene films in which African Americans ever appeared. By the 1960s, youthful drug use had become an actual concern for Americans, and drug films became a staple of the social guidance field. Nonetheless, marijuana was still shown inevitably to produce immediate mental deterioration and to lead inevitably to use of narcotics or LSD. In the 1967 version of Narcotics: Pit of Despair, the protagonist laughs maniacally after one puff of marijuana. As in earlier films, excruciating withdrawal is depicted, but then the young man is sent to a hospital where "the very best treatment modern science can give" is available.

Every cliché about drugs that you have heard has been memorialized in one of these drugs films - yes, LSD users stare at the sun until they go blind in the officially-titled LSD-25 (1967). Flashbacks are documented in Trip to Where (1968) and Curious Alice (1969). Marijuana (1968) was narrated by Sonny Bono, whom Smith reports "looks and sounds as if he were stoned." The pot smoker in this film stares at himself in a mirror - "until his face is replaced by a rubber monster mask!" Of course, while claiming to educate, these films imitated the drug exploitation films of the 1960s (like Roger Corman's 1967 The Trip), Hollywood films about narcotics use (like Otto Preminger's 1955 The Man with the Golden Arm), and the most famous drug film of all, the 1930s' Reefer Madness. The filmmakers simply could not ween themselves from their moral crusades no matter how scientific-seeming the film was purported to be - in Drugs and the Nervous System (made in 1972, the most recent film included in this book), LSD users run into traffic because they "believe they are God." Indeed, it is their growing isolation from reality that, in Smith's view, drove the standard mental hygiene film into extinction, replaced by more open-ended, 1970s "discussion" films.

Whereas, Smith feels, "In the late 1940s and early 1950s, when kids wanted to conform, they [mental hygiene films] were effective. In the late 1960s, when kids didn't, they were not." Even the irrepressible Sid Davis was moved to simulate greater reality in Keep Off the Grass (1970). In this film, mom finds a reefer in Tom's room. Tom's dad lectures him, "prolonged use may result in a loss of ambition. . . ." [the ultimate downer in Davis world]. Tom learns from several cops that, "Not every pot smoker goes on to heroin, of course. A personality factor is undoubtedly largely responsible for that step." But, then, Davis could not resist then speculating, "Very likely the same personality factor which turned the user onto pot!" As we can see, Davis could not remove the blinders of the genre.

Yet, we may inquire how much American educational films and public health messages have changed since the heyday of the social guidance movie. AIDS is even superior to syphilis for warning adolescents to avoid sex, even though it is virtually impossible that an adolescent will contract the HIV virus in sexual intercourse with another non-drug-injecting teenager. The Center on Addiction and Substance Abuse (CASA) - whose president Joseph A. Califano, Jr. is former Secretary of the U.S. Department of Health, Education, and Welfare - has recently repopularized the "progression" model of drug use depicted in these films with the "gateway" model. Califano and his colleagues point out that heroin addicts nearly all began their drug-use careers by smoking marijuana and cigarettes and drinking alcohol (although microscopically few alcohol or marijuana users become heroin addicts). In a fraction of the 10 minutes required for a mental hygiene film, ads by the Partnership for a Drug Free America present the identical picture of the consequences of drug experimentation.

In fact, the lesson of the mental hygiene film seems to be that American moralism about personal behavior is inextinguishable. Media messages convey the same inexorable progression from pleasure to perdition that American blue-stockings have always maintained - a message largely absent when Europeans deal with drugs, alcohol, and sex. Likewise, the obsessiveness and fear-based nature of public health education, and of the American view of the world, still seems to be a distinctive characteristic of the American psyche.

In any case, I can't wait for the film version of Mental Hygiene.

next: What Do I Do when I Find an Adoptive Baby has Special Problems Possibly Related to Her Mother's Drug Use?
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"What's to become of me?" you say?

That may be the wrong question. What more is to become of me? Ask yourself that question and see what comes up. You always want to be working on the more of you which is the best of the rest of you! What's left? What more can you contribute to others than by always working on really being more than you have been for yourself and for them? The emphasis is on being. Be. Become.

Become more than you are!

What you think about is what you are becoming. Thinking about what you have thought about in the past is what got you to this point. Look forward to the present. What you are thinking right now contributes to who and what more will become of you. Becoming more than you are happens when you make the decision to only think and live who you really are becoming.

You are what you think!

When you become more than you are, you accomplish not only the personal rewards that come with doing the best you can, you become an accomplishment from which others can model. What is the more that you can become? Think about it! Only work on that, and all the other stuff you value will fall in line in good order and for the good of all concerned.

Think of yourself as an accomplishment!

Are you proud of you as an accomplishment? Are you proud of the example you are for others to become? To take a liberty with one of my favorite good thoughts, "Let your light so shine that others may feel the accomplishment you are."

You don't have to believe that you make a difference for it to be true!

Look at your children. Look at your significant other. Look at those around you that mean the most. Think of the times you did good and you knew it and you knew that they knew it. Look at yourself and love yourself for doing the best you could, even when it didn't feel like it. You never, ever should look at what didn't work except to learn from the experience. The past is not changeable. There is no future in it.

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The future is up to you!

It's true that others are influenced by your speaking and your actions in many, many different ways. Keep looking forward. That was then. . . this is now!

What more is to become of you?

What personal project could you be working on? How about your relationship with yourself first, then relationships with others. You know, the project you can put all of your energy in, because you know that it feeds on the energy you give it. That personal project knows the law of circulation. It gives energy back to you. You both win! And others around you are indeed influenced by that. You begin to see them as winners becoming. Now. . . what about you?

What more is to become of you?

next: The Truth About Relationship Expectations

If you want to keep your significant other happy and content - do things for her. Willingly.

Run errands. Surprise her by filling her car with gas. Switch roles for a day.

Offer to help with a chore she doesn't particularly enjoy doing. The fact that you offer may come as a pleasant surprise.

Pick something you really don't like to do and do it "without grumbling" while you do it. The secret is to not tell her you don't like it and focus on the fact that although you don't like to do it you know the affect it will have on your relationship.

Men often have a need to grumble while doing something they don't like. When you make a choice not to grumble, your partner will most likely reward you by helping you fulfill one of your basic needs: approval. There could be other needs but face it, you like to be recognized for your accomplishments no matter how small.

Remember, foreplay begins with taking out the garbage "without being asked!

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next: What's to Become of You?

Young, K, Cooper, A., Buchanan, J, & O'Mara, J. (in press) Cybersex and Infidelity Online: Implications for evaluation and treatment. Sexual Addiction and Compulsivity. Young, K, Buchanan, J, & O'Mara, J. (in press) Cyber-disorders: The mental health concern for the millennium. CyberPsychology and Behavior. Young, K. S. (October 25, 1999). Seller as Psychologist: Understanding E-Auction Behavior. Auctionwatch.com. Young, K.S. (1999).

How to Evaluate and Treat Internet Addiction. Student Bristish Journal of Medicine. 7, 351-352. Young, K.S. (1999) Factors related to deviant behavior online. Horizons Newsletter, Published by the Michigan Council on Sexual Abuse and Deviancy. 1 (2), 8. Young, K.S. (1999).

Internet Addiction: Symptoms, Evaluation and Treatment. L. VandeCreek & Jackson (eds). Innovations in Clinical Practice: A Source Book, vol. 17, 19-31. Young, K.S. (1998). Internet Misuse in the Workplace. Credit Union Management, pages 42-43. Young, (2/28/99) "In My View" for The Sunday Post (London), pages 28-29. Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. CyberPsychology and Behavior, 3 (1), 237-244. Young, K.S. & Rodgers, R. C. (1998).

The relationships between depression and Internet addiction. CyberPsychology and Behavior, 1, 25-28. Young, K.S. (September, 1998). How to treat clients addicted to the Internet. The National Psychologist, 8(5), 2B-3B. Young, K. S. (1998) Caught in the Net: How to Recognize Internet addiction and A Winning Strategy for Recovery. New York, NY: John Wiley & Sons, Inc. Young, K. S. (1996) Addictive use of the Internet: A case that breaks the stereotype. Psychological Reports. 79, 899-902. Young, K.S. (1996)

Internet Junkies: Confessions from behind the screen. American Federation of Teachers' On Campus, 16(2), p. 18. Letter to Editor, The Chronicle of Higher Education, April 8, 1996. Carrol, E. N., Young, K. S., & Wilson, S. L. (second revision review). EMG feedback-guided rehabilitation of writing function in a quadriplegic male with intention tremor, oppensplasty and flexor tendon transfers. Rehabilitation Psychology Naugle, R. I., Young, K. S., Tucker, G. D., Chelune, G. J., & Luders, H. O. (in preparation) Subjective memory estimates and objective findings with temporal lobectomy patients. Young, K. S. & Rodgers, R. (in preparation). Therapists' attitudes and treatment approaches to pathological Internet use. Young, K. S. & Rodgers. R (in preparation).

Personality characteristics and Internet addiction. Young, K.S., O'Mara, J.E., & Pistner, M. (in preparation). Levels of martial satisfaction, loneliness, and psychiatric illness among pathological Internet users. Presentations: Young, K.S. & Pistner, M (1999). Cyber-Disorders: The mental health concern for the new millenium. Paper presented at the 107th Annual Meeting of the American Psychological Association, Boston, MA., August 21, 1999. Young, K.S. (1999). The controversial nature of Internet addiction. Paper presented at the 107th Annual Meeting of the American Psychological Association, Boston, MA., August 21, 1999. Young, K.S. (1999).

Cybersex: How the Internet is creating a new outlet for sexual addiction. Workshop presented at the National Council of Sexual Addiction and Compulsivity National Conference. April 8, 1999. Young, K.S. (1998) Interventions with pathological and deviant populations within an online community. Paper presented at the 106th Annual Meeting of the American Psychological Association, SanFrancisco, CA Young, K.S. (1988) Internet addiction and its personality correlates. Paper presented at the 70th Annual Meeting of the Eastern Psychological Association, Boston, MA. Young, K.S. (1988) The effects of computer misuse on human behavior. Symposia presented at the 70th Annual Meeting of the Eastern Psychological Association. Boston, MA Young, K.S. (1997).

Internet addiction and telecommuting overload: Two sides of the same coin. Telecommute "97, Orlando, FL, November 2, 1997. Young, K.S. (1997) Relationship between Depression and Pathological Internet Use. Paper presented at the Annual Meeting of the American Psychological Association, Chicago, IL, August, 1997. Young, K. S. (1997). What makes the Internet so addictive: Potential explanations for pathological Internet use? Paper presented at the Annual Meeting of the American Psychological Association, Chicago, IL, August, 1997. Young, K. S. (1997)

Relationship between Sensation Seeking Behavior and Pathological Internet Use. Paper presented at the Annual Meeting of the American Psychological Society, Washington, DC, May, 1997. Young, K. S., Rodgers, R.C. (1997) Levels of Depression and Addiction Underlying Pathological Internet Use. Paper presented at the Annual Meeting of the Eastern Psychological Association, Washington, DC, April, 1997 Young, K. S. (1996). Internet Addiction: Symptoms, Consequences, and Evaluation. Paper presented at the Annual Meeting of the New England Council of Mental Health, Portland, Maine, November 22, 1996. Young, K. S. (1996). Internet Addiction: Is it real and how significant are the consequences? Paper presented at the Annual Meeting of the Society for Computers in Psychology, Chicago, IL, October 31, 1996. Young, K. S. (1996).

Internet Addiction: The emergence of a New Clinical Disorder. Poster presented at the Annual Meeting of the American Psychological Association, Toronto, Canada, August, 1996. Young, K. S. (1996). The Addictive Reinforcers Underlying Internet Addiction Disorder. Poster presented at the Annual Meeting of the American Psychological Society, San Francisco, CA, June, 1996. Young, K. S ., & VandeCreek, L. D. (1996).

Ethnic Minority Selection Procedures in Clinical Psychology Graduate Admissions. Paper presented at the Annual Meeting of the Eastern Psychological Association, Philadelphia, PA, March, 1996. Young, K. S., & VandeCreek, L. D. (1996). The Reliability and Validity of the Personal Interview among Professional Clinical Psychology Programs. Paper presented at the Annual Meeting of the Eastern Psychological Association, Philadelphia, PA, March, 1996. Naugle, R. I., Chelune, G. J., Tucker, G. D., Young, K. S. , & Luders, H.O. (1994). Self-Report of Memory is Related to Formal Examination Results. Paper presented at the American Epilepsy Society, New Orleans, LO., August, 1994. Zanich, M. L., Grover, D. E., & Young, K. S., (1994).

Barriers to Academic Achievement for Career Women in Psychology. Paper presented at the Annual Meeting of the American Psychological Society, Washington, DC, July, 1994. Young, K. S., (1993). Cardiac Rehabilitation and Spousal Support. Paper presented at the meeting of the State System of Higher Education, Slippery Rock University, PA, March, 1993 . Young, K. S., (1993). Smoking Cessation Techniques and their Efficacy. Paper presented at the meeting of the State System of Higher Education, Slippery Rock University, PA, March, 1993 . Young, K. S., & McHugh, M. (1992). Testimonies of the Breaking Up Process: A Qualitative Analysis. Paper presented at the Association of Women in Psychology National Convention, Long Beach, CA, March, 1992.

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Is it possible that someone who went thru heroin withdrawal with Clonidine (last dose heroin 12 days ago) Clonidine patch removed 2 days ago, suddenly have severe heroin withdrawal symptoms (freq. vomiting, diarrhea, "gooseflesh", shakes)?

Dear Anonymous:

I am not an expert on Clonidine-managed withdrawal. If you read my site, you will see that I view withdrawal as highly situationally and psychologically determined. In this view, it would certainly be possible to encounter withdrawal symptoms from only a small maintenance dose of a narcotic, and this happens. "Addicts" report withdrawal with often quite minimal exposure to narcotics. On the other hand, withdrawal has often been overcome readily through social milieu therapy (being in a rich, involving environment where anticipation of withdrawal is minimized because the focus is elsewhere).

Don't despair. Report your experience to the physician I assume supervised your Clonidine therapy if you have not done so. Obviously, you may be somewhat skeptical about his or her ability to predict or manage your condition. But you have to take responsibility for your withdrawal. The proof is in your engagement in the post-withdrawal activities of life — family, work, health, positive use of spare time — and in the development of a range of positive activities to construct your life.

Regards, Stanton

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Many problems children with ADHD face have a direct relationship with poor social skills. Here's an analysis plus strategies for enhancing your ADHD child's social skills.

Problems with impulse control, attention, and related issues, means that our ADHD children tend to find integrating with their peers very difficult.

Our children with ADHD will often butt into conversations, not wait their turn in a queue or in a game. They often think of something which they really need to say before they forget it. Generally not being able to communicate at the same level as their peers - it is generally felt through a lot of the research which has been carried out, that children with conditions like ADHD develop at approximately 3 years below their peers in their emotional and comprehension abilities. This makes it very difficult for them to interact with other children of the same age. They will very often get on really well with younger children who they obviously feel more able to communicate with or with older children or adults; as they do not feel as threatened when in conversation or interaction with these groups.

It is very difficult for them to understand all that is going on around them due to lack of attention and concentration they will often not be able to follow the flow of conversation and therefore will then often make inappropriate remarks to get back to the centre of attention!

What Causes Children with ADHD to Have Peer Problems?

However, first we need to consider a number of the main problems which hamper our children from being able to interact as well with their peers.

These can include:

a)Inhibited peer interactions or social relationships - the children may appear solitary, preferring their own company, even resisting any "invasion" of their space by others. They may seek interaction but are uncertain how to approach other children, fail to give out or read the appropriate social signals, and do not appreciate how behaviour may need to vary according to circumstances. They may appear actively anti-social.

b)Limited communication - vocabulary knowledge and articulator skills may be adequate but there is poor use of language, and communication may be one-sided and eventually break down altogether. There may be an obsessive repetition of the same questions or, at least, an insistence on focusing upon one topic. Understanding is often literal with an inability to understand humour or idioms. Tone of voice tends to be monotonous, the face may remain expressionless, and there is minimal use or understanding of non-verbal signals (including when the other person is becoming irritated).

c)A lack of imaginative play or flexible thinking - there is a common lack of true interactive play with other children so that the children with ADHD may focus upon individual activities and appear obsessed with some particular object or set of objects. They may seek to impose their choice of games upon others and may not be able to take part in "pretend" games.

Children with ADHD also commonly fail to understand that other people may have and are entitled to have opinions, attitudes, or knowledge which differ from their own. They are likely to assume, instead, that others share their outlook and will be immediately able to tune into what they say and to understand what they are talking about without the need for introduction. If there is no awareness of what someone else might be thinking or feeling, it will not be possible to make sense of that person's actions or to anticipate their reactions to a given situation or event.

Other difficulties which can include a resistance to change and anxiety at the prospect of an interruption to routines ( or distress/anger if someone makes any change in the way toys or belongings have been set out). They really do prefer things to stay the same.

Other Difficulties Faced by ADHD Children

Some of our children may also have awkward motor skills, a clumsiness, and impaired ability to run or throw or catch. Where, some children may show an exaggerated response to touch or sound, or display a sensory defensiveness.

Finally, these children may show a kind of innocence in not recognising teasing but a tendency to comply with being told to perform some unacceptable or silly action and then fail to comprehend why the other children laugh at them or why they are the ones who end up getting into trouble, they are also then unable to explain why they have done these things so will often end up lying about them, some can almost convince you that black is white as they are so adamant about things which can then lead them into even more trouble. The other thing that often ends up happening is that they get so used to getting into trouble and others being believed over them that they start to lose self esteem, confidence and sense of self worth with is a very sad and serious consequence of their lack of social skills.

In respect of anxiety, the technique involving "Social Stories" may be very helpful in individual work with a given child to reduce his or her anxiety over some identified activity or circumstance during the school day, with the implication that, if the negative thoughts and anticipations can be largely eliminated, the child will no longer feel the need to set him/herself apart or avoid significant parts of the school experience.

For example, in the initial description of the use of Social Stories, Gray (1995) refers to a child who is intimidated by the general noise in the dining hall but is encouraged to recognise that there is no need for anxiety so that (s)he can join peers in what is a particularly important, socially-speaking, part of the school day. Research has confirmed that this approach is very useful for the ADHD child given its visual format, the use of simple language, the explicitness, and availability for repeated usage.

It needs also to be remembered that the child with ADHD may experience a range of negative emotions but not be able to label them or to express them to other people. The implication is for some help in recognising anxiety, in establishing some message or signal by which the child can make clear when anxiety or stress or anger is building up, and taking time to explore the reasons behind the feelings.

It is likely that a significant source may be the apparent unpredictability of the world, with the child with ADHD developing rituals by which to increase feelings of stability. Everything must remain in a certain place ; activities must be followed in the same sequence ... and the "free" social and play activities of various groups of children during school break times may be a particular source of the perceptions of unpredictability and feelings of insecurity, with the child motivated by a wish to escape from this setting.

Social Skills Groups Can Help Your ADHD Child Develop Social Skills

There are a number of ways to help our children to overcome a lot of these problems. Obviously professional Social Skills Groups are the best option and all of our children would really benefit from these. However, these are so rarely available that it is probably a good idea to try to incorporate as much as we can into daily life until these groups start to appear.

Social Skills Groups can be found via the local Child and Adolescent Mental Health Services, some schools will run these during the school day for small groups and also the local Social Services Children's Service can arrange to hold these. The thing is that it does not cost a great deal in money terms to set something like this up and there are a lot of great materials around which you can get to help with this. Check out our Books and Resources Section - Social Skills.

I found a copy of a great board game basically called "The Social Skills Game" which I got a copy of and lent to my son's small school unit. Some of the children and teachers have written some great reviews for this. For an initial layout of approximately £40, this can be used over and over with many groups of children so it would be a great investment for many schools who would be prepared to work with a group of up to say 6 children for no more than about 15 minutes twice or three times a week either during lesson time or maybe over a break time or lunch time. One of the bits I found the children loved when we used this was the part where they each had to whisper something, then they had to shout it as loud as they could. Well, of course, they all tried to out-shout each other, but it was great fun and they did learn a lot from it.

There are also a lot of activity and other books including The Social Stories Book by Carol Grey which is based on cartoon strip of everyday things. The book can be used to discuss appropriate situations and how to handle things. A CD Rom called Gaining Face was also used at the school. This has various faces to enable the child to learn about facial expressions.

On a larger scale, there is an Interactive CD Rom from Behaviour UK called the Conduct Files which can be purchased by the LEA and used in a number of schools on a license basis. The CD is for both primary school and senior school age groups and uses video clips and then questions to ask the children how they could handle the situation better than the child on the video.

It all depends on how much the group is able to invest, but anything that is purchased can be used for a number of years with a lot of children. So these more than pay for themselves over time.

All of these are, of course, available for parents to purchase as well so maybe a group of parents could get together and get some of these to use with their own group of children to help them as no particular qualifications are really needed to do this. Obviously, to have groups run by professionals is probably the best option as then there are people there who can work with the children on other levels as well. In addition, it's very likely that after doing one of two of the sessions, some children may have specific questions which may be best dealt with by a therapist, teacher or social worker. But on the whole, parents are quite able to run these groups as a starting point at least. This may also provide the evidence which could then be passed onto the authorities to show what need there is in your area for such groups to be run officially.

What Else Can Be Done to Improve Social Skills and Peer Interaction?

As mentioned above, it is possible to do a lot of things in everyday circumstances and with our children on our own. However, as we go through a number of things which are important for them to be able to learn, our children often start to question things which they may have come across and do not understand. Some of these may be better answered by a professional running a specific group as they can go through things from a less emotionally-attached point-of-view. Unfortunately, until these groups become more common, then we must do the best we can to help our children learn some of the vital skills they need to reach their full potential.

Once you have worked on these things with your own individual child, then try to involve other children as well. These could be other classmates who do not have specific problems, or siblings, or even other children who have similar problems to your own child, to get them used to working in a group. Try out some of the skills you are working on with them. You will need to be there in the middle of things even if you have a friend over to play a game to make sure that they are sticking to the rules, taking turns and actually playing with the friend, rather than just being in the same room! It can be fairly intensive, so short periods of doing this is quite enough for both you and your child or tempers can start to fray!

REFERENCES

• Roeyers H. 1996 The influence of non-handicapped peers on the social interaction of children with a pervasive developmental disorder. Journal of Autism and Developmental Disorders 26 307-320
• Novotini M 2000 What Does Everyone Else Know That I Don't
• Connor M 2002 Promoting Social Skills among Children with Asperger Syndrome (ASD)
• Gray C My Social Stories Book
• Searkle Y, Streng I The Social Skills Game (Lifegames)
• Behaviour UK Conduct Files
• Team Asperger Gaining Face, CD Rom Game

Many adults with ADHD are undiagnosed and have a limited awareness of how ADHD-related behaviors cause problems for themselves and others.

ADHD Makes You Feel Driven to Distraction

If your idea of someone who has attention deficit hyperactivity disorder (ADHD) is a school-age boy or girl who can't sit still in class, can't complete assignments, distracts other children, talks inappropriately, and has poor impulse control, then you're missing a big part of the ADHD picture.

"About 5% of school-age children have ADHD, but this is a chronic condition, it doesn't go away, and what we see is that as many as two-thirds of children with ADHD will become adults with ADHD," says Oscar Bukstein, MD, associate professor of psychiatry at the University of Pittsburgh Medical Center's Western Psychiatric Institute and Clinic.

For adults, untreated or undiagnosed ADHD is a particularly nasty condition. Children with behavioral problems may get poor marks and have difficulty fitting in with others. But many adults with ADHD have to deal with difficulty holding jobs, financial problems due to poor decision making, substance abuse, and troubled interpersonal relationships.

Trouble at Home and Work

"Most adults with ADHD are not hyperactive, but they may seem fidgety and verbally impulsive," says Bukstein. "Family troubles are common because these people may say stupid things and forget birthdays and anniversaries and have trouble at work. We often see ADHD combined with other problems, such as depression and learning disability."

This combination of disorders -- what doctors call comorbidity -- was highlighted in a recent report from the CDC.

According to the report, which used data collected in 1997-98, about one-half of the 1.6 million school-aged children diagnosed with ADHD have been identified with an accompanying learning disability. And this also appears to hold true of adults.

"This report reinforces what the leading scientific institutions have been telling us all along," says Clarke Ross, CEO of Children and Adults with Attention-Deficit/Hyperactivity Disorder, or CHADD, a nonprofit support group. "Nearly 70% of those with ADHD simultaneously cope with other conditions such as learning disabilities, mood disorders, anxiety, and more."

But these complex problems have nothing to do with a lack of intelligence or motivation.

"Many people with ADHD are labeled lazy, incompetent or stupid," says Bukstein. "But that's not the case. I've had very bright patients with ADHD. One computer programmer I treated had an IQ of 170, but outside of the tasks of computer programming he couldn't think his way out of a wet paper bag."

Treating ADHD in Adults

Despite increased awareness and identification of the disorder in adults, many adults remain unidentified and untreated, says Ross. Part of the problem is that while ADHD is well-documented in children, it's symptoms tend to be vague in adults. That's one reason, according to CHADD, that the disorder should only be diagnosed by an experienced and qualified medical professional.

"Many AD/HD patients initially seek help for other problems," says Bukstein, such as difficulty with relationships, organization, mood disorders, substance abuse, employment, or after the person's child has been diagnosed with it.

The good news about ADHD is that it is highly treatable. In children, stimulants like Ritalin and dexedrine are effective in up to 80% of cases, says Bukstein, and works for about 60% of adults.

"Talk therapy for ADHD adults can be useful," he says, adding that improving decision making, time management, and organization are often the goals of such therapy.

"Some studies have shown that buproprion (Wellbutrin) can work as well as stimulants in some people, and it has the advantage of being an antidepressant, so, obviously, that can work well for people who have depression along with ADHD," says Bukstein.

A non-stimulant drug, Strattera, has also proven helpful in the treatment of adult ADHD. "It's not looking as good as stimulants, but it seems like it is better than any of the other non-stimulant medications," says Bukstein.

But it's getting that diagnosis that is all-important.

"The tragedy here is that many people still don't know that this very treatable problem can affect adults," says Bukstein. "It's even worse than adults who have high blood pressure or diabetes without knowing it because these people live with the ongoing damage their whole lives."

SOURCES: Oscar Bukstein, MD, associate professor of psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic - Clarke Ross, CEO, Children and Adults with Attention-Deficit/Hyperactivity Disorder - CDC

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More students report they are addicted to their computers, and their studies and social lives are suffering as a result.

It's 4 a.m. and 'Steve' is engulfed in the green glare of his computer screen, one minute pretending he's a ruthless mafia lord masterminding a gambling empire, the next minute imagining he's an evil sorcerer or an alien life form.

Steve, a college student, is playing a Multiple User Dungeon (MUD) game-a fictional game modeled after Dungeons and Dragons that is played by sending online messages to other players. But as he continually logs on hours, Steve finds himself sleeping through classes, forgetting his homework and slipping into 'Internet addiction'-a disorder emerging on college campuses. Affected students spend up to 40 hours to 60 hours a week in MUDs, e-mail and chat rooms, racking up online time unrelated to their school work.

'These people stay on their computers from midnight 'til the sun comes up,' said Jonathan Kandell, PhD, assistant director of the counseling center at the University of Maryland-College Park. 'It becomes a downward spiral they get sucked into.'

Internet addiction can afflict anyone who has easy access to the plethora of online services, but students seem especially prone to it. As universities increasingly give students their own free Internet accounts, psychologists like Kandell and Kimberly Young, PhD, of the University of Pittsburgh-Bradford, have noticed them spending larger amounts of time online, sometimes to the detriment of their social lives and studies.

'For many students this is a very real problem,' says Young. 'Some of them are saying it's destroying their lives.'

Few students seek help for 'Internet addiction' per se. But in intake interviews, many of them say they recognize that they go online to escape, university counseling centers report. Some students say they feel fidgety and nervous during every minute of 'offline' time and claim they go online to avoid life's pressures.

Cyberpill

Young likens Internet addiction to any other form of addiction: It becomes a problem when it interferes with other parts of peoples' lives, such as sleep, work, socializing and exercise.

'Some of these people even forget to eat,' she says.

The Internet can be a healthy, helpful tool when used to find information or to communicate with friends, co-workers and professors, she said. But people become dependent on it when they use it mainly to fill their time, and may even lose the ability to control that use.

'Substitute the word 'computer' for 'substance' or 'alcohol,' and you find that Internet obsession fits the classic 'Diagnostic Statistical Manual' definition of addiction,' says Young.

People seek the same escapist, pleasurable feelings from the Internet that they seek from drugs, gambling or alcohol, she believes. Gambling gives them a high, alcohol numbs them and the Internet offers them an alternate reality. Just as people struggle to keep from taking a drink or popping a pill, they struggle to turn their computer off, she said. And the Internet can serve as a tonic for students with underlying social problems, depression or anxiety.

Paradoxically, the Internet's usefulness and social acceptability make it easy to abuse, says psychologist Kathleen Scherer, PhD, of the counseling and mental health center at the University of Texas-Austin.

Students will log on to their computer to check e-mail from a professor or to write a paper for their biology class, and then with a simple push of a button, immerse themselves in Internet banter for hours.

'It becomes so easy for students to move between work time and play time that the line between the two gets blurred,' said Scherer.

Plug-in buddy

Another danger of incessant online surfing, is that Internet social interactions can start to replace real social relationships, Scherer warns.

Although some educators argue that television or reading also cut into peoples' social lives, Scherer claims the Internet is more addictive because it offers interaction with other people that ostensibly fills a social void. Stories abound about Internet addicts who lose mates, families and friends, and about students who would rather ask strangers for dates over e-mail than approach them in person.

Students visiting chat rooms or playing MUD games can assume new, glamorous identities. Some start to believe that they're loved and cared for in their new identities-'an illusion that these online relationships are the same as the real thing,' said Kandell.

'Online you have the freedom to talk to anyone, be anything you want and not be censored for it,' he said. 'It's a sort of unconditional acceptance unusual in flesh-and-blood relationships that makes you less used to dealing with real life.'

Students sometimes attach to their computers emotionally and form a distorted view of social interactions, notes psychologist Linda Tipton, PhD, a colleague of Kandell's at Maryland. They spend the evening with their computer instead of going out and meeting people, she said.

Logging off

Psychologists are looking for ways to help Internet junkies overcome their addiction. Hoping to attract the ones who don't come in for counseling-the majority-Tipton last fall offered a campus-wide workshop called 'Caught in the Net.' Only three students attended because, Tipton says, 'it's hard to break through the denial and admit you have a problem.'

Scherer drew a bigger audience for a workshop she hosted at the University of Texas with her husband, computer scientist Jacob Kornerup. Sixteen people, both faculty and students, attended the session, and learned how to control the amount of time they play online, for instance, by stopping their subscriptions to the online services they find most addictive (see sidebar on page 38).

Attendees informally told Scherer that the workshop helped, and some pursued counseling for their addiction. To determine the extent of the problem at the University of Texas, Scherer and psychologist Jane Morgan Bost, PhD, assistant director of the counseling and mental health center, are conducting a study of 1,000 students, some who use the Internet and some who don't. They want to determine the forms the disorder takes and how best they can help afflicted students.

For example, some students may prefer online support services to counseling or workshops, said Scherer. Already the Internet Addiction Support Group, an Internet service recently established by psychiatrist Ivan Goldberg, MD, has begun attracting subscribers. Users of the service own up to their addiction and swap ways to tackle it.

Once addicts can say 'enough is enough,' and deliberately switch the computer off without regret, they're on the way to recovery, said Scherer.

'There are a lot of valuable and not-so-valuable resources on the Internet,' she said. 'To manage your use, you have to know the difference in value and know yourself.

Source: APA Monitor

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Depressive disorders affect approximately 19 million American adults. The suffering endured by people with depression and the lives lost to suicide attest to the great burden of this disorder on individuals, families, and society. Improved recognition, treatment, and prevention of depression are critical public health priorities. The National Institute of Mental Health (NIMH), the world's leading mental health biomedical organization, conducts and supports research on the causes, diagnosis and treatment of depression and the prevention of depression.

Evidence from neuroscience, genetics, and clinical investigation demonstrate that depression is a disorder of the brain. Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters - chemicals used by nerve cells to communicate - are out of balance. Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better treatments.

In the past decade, there have been significant advances in our ability to investigate brain function at multiple levels. NIMH is collaborating with various scientific disciplines to effectively utilize the tools of molecular and cellular biology, genetics, epidemiology, and cognitive and behavioral science to gain a more thorough and comprehensive understanding of the factors that influence brain function and behavior, including mental illness. This collaboration reflects the Institute's increasing focus on "translational research," whereby basic and clinical scientists are involved in joint efforts to translate discoveries and knowledge into clinically relevant questions and targets of research opportunity. Translational research holds great promise for disentangling the complex causes of depression and other mental disorders and for advancing the development of more effective treatments.

Symptoms and Types of Depression

Symptoms of depression include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant change in appetite or body weight; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death or suicide. A diagnosis of major depressive disorder (or unipolar major depression) is made if an individual has five or more of these symptoms during the same two-week period. Unipolar major depression typically presents in discrete episodes that recur during a person's lifetime.

Bipolar disorder (or manic-depressive illness) is characterized by episodes of major depression as well as episodes of mania - periods of abnormally and persistently elevated mood or irritability accompanied by at least three of the following symptoms: overly-inflated self-esteem; decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal-directed activity or physical agitation; and excessive involvement in pleasurable activities that have a high potential for painful consequences. While sharing some of the features of major depression, bipolar disorder is a different illness that is discussed in detail in a separate NIMH publication.

Dysthymic disorder (or dysthymia), a less severe yet typically more chronic form of depression, is diagnosed when depressed mood persists for at least two years in adults (one year in children or adolescents) and is accompanied by at least two other depressive symptoms. Many people with dysthymic disorder also experience major depressive episodes. While unipolar major depression and dysthymia are the primary forms of depression, a variety of other subtypes exist.

In contrast to the normal emotional experiences of sadness, loss, or passing mood states, depression is extreme and persistent and can interfere significantly with an individual's ability to function. In fact, a recent study sponsored by the World Health Organization and the World Bank found unipolar major depression to be the leading cause of disability in the United States and worldwide.

There is a high degree of variation among people with depression in terms of symptoms, course of illness, and response to treatment, indicating that depression may have a number of complex and interacting causes. This variability poses a major challenge to researchers attempting to understand and treat the disorder. However, recent advances in research technology are bringing NIMH scientists closer than ever before to characterizing the biology and physiology of depression in its different forms and to the possibility of identifying effective treatments for individuals based on symptom presentation.

The National Institute of Mental Health (NIMH) is one of 25 components of the National Institutes of Health (NIH), the Government's principal biomedical and behavioral research agency. NIH is part of the U.S. Department of Health and Human Services. The actual total fiscal year 1999 NIMH budget was $859 million.

NIMH Mission

To reduce the burden of mental illness through research on mind, brain, and behavior.

How Does the Institute Carry Out Its Mission?

One of the most challenging problems in depression research and clinical practice is refractory - hard to treat - depression (treatment-resistant depression). While approximately 80 percent of people with depression respond very positively to treatment, a significant number of individuals remain treatment refractory. Even among treatment responders, many do not have complete or lasting improvement, and adverse side effects are common. Thus, an important goal of NIMH research is to advance the development of more effective treatments for depression - especially treatment-refractory depression - that also have fewer side effects than currently available treatments.

Research on Treatments for Depression

Antidepressant Medication

Studies on the mechanisms of action of antidepressant medication comprise an important area of NIMH depression research. Existing antidepressant drugs are known to influence the functioning of certain neurotransmitters in the brain, primarily serotonin and norepinephrine, known as monoamines. Older medications - tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) - affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to side effects or, in the case of MAOIs, dietary restrictions. Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for patients to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.

Antidepressant medications take several weeks to be clinically effective even though they begin to alter brain chemistry with the very first dose. Research now indicates that antidepressant effects result from slow-onset adaptive changes within the brain cells, or neurons. Further, it appears that activation of chemical messenger pathways within neurons, and changes in the way that genes in brain cells are expressed, are the critical events underlying long-term adaptations in neuronal function relevant to antidepressant drug action. A current challenge is to understand the mechanisms that mediate, within cells, the long-term changes in neuronal function produced by antidepressants and other psychotropic drugs and to understand how these mechanisms are altered in the presence of illness.

Knowing how and where in the brain antidepressants work can aid the development of more targeted and potent medications that may help reduce the time between first dose and clinical response. Further, clarifying the mechanisms of action can reveal how different drugs produce side effects and can guide the design of new, more tolerable, treatments.

As one route toward learning about the distinct biological processes that go awry in different forms of depression, NIMH researchers are investigating the differential effectiveness of various antidepressant medications in people with particular subtypes of depression. For example, this research has revealed that people with atypical depression, a subtype characterized by reactivity of mood (mood brightens in response to positive events) and at least two other symptoms (weight gain or increased appetite, oversleeping, intense fatigue, or rejection sensitivity), respond better to treatment with MAOIs, and perhaps with SSRIs than with TCAs.

Many patients and clinicians find that combinations of different drugs work most effectively for treating depression, either by enhancing the therapeutic action or reducing side effects. Although combination strategies are used often in clinical practice, there is little research evidence available to guide psychiatrists in prescribing appropriate combination treatment. NIMH is in the process of revitalizing and expanding its program of clinical research, and combination therapy will be but one of numerous treatment interventions to be explored and developed.

Untreated depression often has an accelerating course, in which episodes become more frequent and severe over time. Researchers are now considering whether early intervention with medications and maintenance treatment during well periods will prevent recurrence of episodes. To date, there is no evidence of any adverse effects of long-term antidepressant use.

Psychotherapy

Like the process of learning, which involves the formation of new connections between nerve cells in the brain, psychotherapy works by changing the way the brain functions. NIMH research has shown that certain types of psychotherapy, particularly cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), can help relieve depression. CBT helps patients change the negative styles of thinking and behaving often associated with depression. IPT focuses on working through disturbed personal relationships that may contribute to depression.

Research on children and adolescents with depression supports CBT as a useful initial treatment, but antidepressant medication is indicated for those with severe, recurrent, or psychotic depression. Studies of adults have shown that while psychotherapy alone is rarely sufficient to treat moderate to severe depression, it may provide additional relief in combination with antidepressant medication. In one recent NIMH-funded study, older adults with recurrent major depression who received IPT in combination with an antidepressant medication during a three-year period were much less likely to experience a recurrence of illness than those who received medication only or therapy only. For mild depression, however, a recent analysis of multiple studies indicated that combination treatment is not significantly more effective than CBT or IPT alone.

Preliminary evidence from an ongoing NIMH-supported study indicates that IPT may hold promise in the treatment of dysthymia.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) remains one of the most effective yet most stigmatized treatments for depression. Eighty to ninety percent of people with severe depression improve dramatically with ECT. ECT involves producing a seizure in the brain of a patient under general anesthesia by applying electrical stimulation to the brain through electrodes placed on the scalp. Repeated treatments are necessary to achieve the most complete antidepressant response. Memory loss and other cognitive problems are common, yet typically short-lived side effects of ECT. Although some people report lasting difficulties, modern advances in ECT technique have greatly reduced the side effects of this treatment compared to earlier decades. NIMH research on ECT has found that the dose of electricity applied and the placement of electrodes (unilateral or bilateral) can influence the degree of depression relief and the severity of side effects.

A current research question is how best to maintain the benefits of ECT over time. Although ECT can be very effective for relieving acute depression, there is a high rate of relapse when the treatments are discontinued. NIMH is currently sponsoring two multicenter studies on ECT follow-up treatment strategies. One study is comparing different medication treatments, and the other study is comparing maintenance medication to maintenance ECT. Results from these studies will help guide and improve follow-up treatment plans for patients who respond well to ECT.

Genetics Research

Research on the genetics of depression and other mental illnesses is a priority of NIMH and constitutes a critical component of the Institute's multi-level research effort. Researchers are increasingly certain that genes play an important role in vulnerability to depression and other severe mental disorders.

In recent years, the search for a single, defective gene responsible for each mental illness has given way to the understanding that multiple gene variants, acting together with yet unknown environmental risk factors or developmental events, account for the expression of psychiatric disorders. Identification of these genes, each of which contributes only a small effect, has proven extremely difficult.

However, new technologies, which continue to be developed and refined, are beginning to allow researchers to associate genetic variations with disease. In the next decade, two large-scale projects that involve identifying and sequencing all human genes and gene variants will be completed and are expected to yield valuable insights into the causes of mental disorders and the development of better treatments. In addition, NIMH is currently soliciting researchers to contribute to the development of a large-scale database of genetic information that will facilitate efforts to identify susceptibility genes for depression and other mental disorders.

Stress and Depression

Psychosocial and environmental stressors are known risk factors for depression. NIMH research has shown that stress in the form of loss, especially death of close family members or friends, can trigger depression in vulnerable individuals. Genetics research indicates that environmental stressors interact with depression vulnerability genes to increase the risk of developing depressive illness. Stressful life events may contribute to recurrent episodes of depression in some individuals, while in others depression recurrences may develop without identifiable triggers.

Other NIMH research indicates that stressors in the form of social isolation or early-life deprivation may lead to permanent changes in brain function that increase susceptibility to depressive symptoms.

Brain Imaging

Recent advances in brain imaging technologies are allowing scientists to examine the brain in living people with more clarity than ever before. Functional magnetic resonance imaging (fMRI), a safe, noninvasive method for viewing brain structure and function simultaneously, is one new technique that NIMH researchers are using to study the brains of individuals with and without mental disorders. This technique will enable scientists to evaluate the effects of a variety of treatments on the brain and to associate these effects with clinical outcome.

Brain imaging findings may help direct the search for microscopic abnormalities in brain structure and function responsible for mental disorders. Ultimately, imaging technologies may serve as tools for early diagnosis and subtyping of depression and other mental disorders, thus advancing the development of new treatments and evaluation of their effects.

Hormonal Abnormalities

The hormonal system that regulates the body's response to stress, the hypothalamic-pituitary-adrenal (HPA) axis, is overactive in many patients with depression, and NIMH researchers are investigating whether this phenomenon contributes to the development of the illness.

The hypothalamus, the brain region responsible for managing hormone release from glands throughout the body, increases production of a substance called corticotropin releasing factor (CRF) when a threat to physical or psychological well-being is detected. Elevated levels and effects of CRF lead to increased hormone secretion by the pituitary and adrenal glands which prepares the body for defensive action. The body's responses include reduced appetite, decreased sex drive, and heightened alertness. NIMH research suggests that persistent overactivation of this hormonal system may lay the groundwork for depression. The elevated CRF levels detectable in depressed patients are reduced by treatment with antidepressant drugs or ECT, and this reduction corresponds to improvement in depressive symptoms.

NIMH scientists are investigating how and whether the hormonal research findings fit together with the discoveries from genetics research and monoamine studies.

Co-occurrence of Depression and Anxiety Disorders

NIMH research has revealed that depression often co-exists with anxiety disorders (panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, social phobia, or generalized anxiety disorder). In such cases, it is important that depression and each co-occurring illness be diagnosed and treated.

everal studies have shown an increased risk of suicide attempts in people with co-occurring depression and panic disorder - the anxiety disorder characterized by unexpected and repeated episodes of intense fear and physical symptoms, including chest pain, dizziness, and shortness of breath.

Rates of depression are especially high in people with post-traumatic stress disorder (PTSD), a debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. In one study supported by NIMH, more than 40 percent of patients with PTSD had depression when evaluated both at one month and four months following the traumatic event.

Co-occurrence of Depression and Other Illnesses

Depression frequently co-occurs with a variety of other physical illnesses, including heart disease, stroke, cancer, and diabetes, and also can increase the risk for subsequent physical illness, disability, and premature death. Depression in the context of physical illness, however, is often unrecognized and untreated. Furthermore, depression can impair the ability to seek and stay on treatment for other medical illnesses. NIMH research suggests that early diagnosis and treatment of depression in patients with other physical illnesses may help improve overall health outcome.

The results of a recent NIMH-supported study provide the strongest evidence to date that depression increases the risk of having a future heart attack. Analysis of data from a large-scale survey revealed that individuals with a history of major depression were more than four times as likely to suffer a heart attack over a 12-13 year follow-up period, compared to people without such a history. Even people with a history of two or more weeks of mild depression were more than twice as likely to have a heart attack, compared to those who had had no such episodes. Although associations were found between certain psychotropic medications and heart attack risk, the researchers determined that the associations were simply a reflection of the primary relationship between depression and heart trouble. The question of whether treatment for depression reduces the excess risk of heart attack in depressed patients must be addressed with further research.

NIMH is planning to present a major conference with other NIH Institutes on depression and co-occurring illnesses. The outcomes of this conference will guide NIMH investigation of depression both as a contributing factor to other medical illnesses and as a result of these illnesses.

Women and Depression

Nearly twice as many women (12 percent) as men (7 percent) are affected by a depressive illness each year. At some point during their lives, as many as 20 percent of women have at least one episode of depression that should be treated. Although conventional wisdom holds that depression is most closely associated with menopause, in fact, the childbearing years are marked by the highest rates of depression, followed by the years prior to menopause.

NIMH researchers are investigating the causes and treatment of depressive disorders in women. One area of research focuses on life stress and depression. Data from a recent NIMH-supported study suggests that stressful life experiences may play a larger role in provoking recurrent episodes of depression in women than in men.

The influence of hormones on depression in women has been an active area of NIMH research. One recent study was the first to demonstrate that the troublesome depressive mood swings and physical symptoms of premenstrual syndrome (PMS), a disorder affecting three to seven percent of menstruating women, result from an abnormal response to normal hormone changes during the menstrual cycle. Among women with normal menstrual cycles, those with a history of PMS experienced relief from mood and physical symptoms when their sex hormones, estrogen and progesterone, were temporarily "turned off" by administering a drug that suppresses the function of the ovaries. PMS symptoms developed within a week or two after the hormones were re-introduced. In contrast, women without a history of PMS reported no effects of the hormonal manipulation. The study showed that female sex hormones do not cause PMS - rather, they trigger PMS symptoms in women with a preexisting vulnerability to the disorder. The researchers currently are attempting to determine what makes some women but not others susceptible to PMS. Possibilities include genetic differences in hormone sensitivity at the cellular level, differences in history of other mood disorders, and individual differences in serotonin function.

NIMH researchers also are currently investigating the mechanisms that contribute to depression after childbirth (postpartum depression), another serious disorder where abrupt hormonal shifts in the context of intense psychosocial stress disable some women with an apparent underlying vulnerability. In addition, an ongoing NIMH clinical trial is evaluating the use of antidepressant medication following delivery to prevent postpartum depression in women with a history of this disorder after a previous childbirth.

Child and Adolescent Depression

Large-scale research studies have reported that up to 2.5 percent of children and up to 8.3 percent of adolescents in the United States suffer from depression. In addition, research has discovered that depression onset is occurring earlier in individuals born in more recent decades. There is evidence that depression emerging early in life often persists, recurs, and continues into adulthood, and that early onset depression may predict more severe illness in adult life. Diagnosing and treating children and adolescents with depression is critical to prevent impairment in academic, social, emotional, and behavioral functioning and to allow children to live up to their full potential.

Research on the diagnosis and treatment of mental disorders in children and adolescents, however, has lagged behind that in adults. Diagnosing depression in these age groups is often difficult because early symptoms can be hard to detect or may be attributed to other causes. In addition, treating depression in children and adolescents remains a challenge, because few studies have established the safety and efficacy of treatments for depression in youth. Children and adolescents are going through rapid, age-related changes in their physiological states, and there remains much to be learned about brain development during the early years of life before treatments for depression in young people will be as successful as they are in older people. NIMH is pursuing brain-imaging research in children and adolescents to gather information about normal brain development and what goes wrong in mental illness.

Depression in children and adolescents is associated with an increased risk of suicidal behaviors. Over the last several decades, the suicide rate in young people has increased dramatically. In 1996, the most recent year for which statistics are available, suicide was the third leading cause of death in 15-24 year olds and the fourth leading cause among 10-14 year olds. NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. However, early diagnosis and treatment of depression and other mental disorders, and accurate evaluation of suicidal thinking, possibly hold the greatest suicide prevention value.

Until recently, there were limited data on the safety and efficacy of antidepressant medications in children and adolescents. The use of antidepressants in this age group was based on adult standards of treatment. A recent NIMH-funded study supported fluoxetine, an SSRI, as a safe and efficacious medication for child and adolescent depression. The response rate was not as high as in adults, however, emphasizing the need for continued research on existing treatments and for development of more effective treatments, including psychotherapies designed specifically for children. Other complementary studies in the field are beginning to report similar positive findings in depressed young people treated with any of several newer antidepressants. In a number of studies, TCAs were found to be ineffective for treating depression in children and adolescents, but limitations of the study designs preclude strong conclusions.

NIMH is committed to developing an infrastructure of skilled researchers in the areas of child and adolescent mental health. In 1995, NIMH co-sponsored a conference that brought together more than 100 research experts, family and patient advocates, and representatives of mental health professional organizations to discuss and reach consensus on various recommendations for psychiatric medication research in children and adolescents. Outcomes of this conference included awarding additional funds to existing research grants to study psychotropic medications in children and adolescents and establishing a network of Research Units of Pediatric Psychopharmacology (RUPPs). Recently, a large, multi-site, NIMH-funded study was initiated to investigate both medication and psychotherapeutic treatments for adolescent depression.

Continuing to address and resolve the ethical challenges involved with clinical research on children and adolescents is an NIMH priority.

Older Adults and Depression

In a given year, between one and two percent of people over age 65 living in the community, i.e., not living in nursing homes or other institutions, suffer from major depression and about two percent have dysthymia. Depression, however, is not a normal part of aging. Research has clearly demonstrated the importance of diagnosing and treating depression in older persons. Because major depression is typically a recurrent disorder, relapse prevention is a high priority for treatment research. As noted previously, a recent NIMH-supported study established the efficacy of combined antidepressant medication and interpersonal psychotherapy in reducing depressive relapses in older adults who had recovered from an episode of depression.

Additionally, recent NIMH studies show that 13 to 27 percent of older adults have subclinical depressions that do not meet the diagnostic criteria for major depression or dysthymia but are associated with increased risk of major depression, physical disability, medical illness, and high use of health services. Subclinical depressions cause considerable suffering, and some clinicians are now beginning to recognize and treat them.

Suicide is more common among the elderly than in any other age group. NIMH research has shown that nearly all people who commit suicide have a diagnosable mental or substance abuse disorder. In studies of older adults who committed suicide, nearly all had major depression, typically a first episode, though very few had a substance abuse disorder. Suicide among white males aged 85 and older was nearly six times the national U.S. rate (65 per 100,000 compared with 11 per 100,000) in 1996, the most recent year for which statistics are available. Prevention of suicide in older adults is a high priority area in the NIMH prevention research portfolio.

Alternative Treatments

There is high public interest in herbal remedies for various medical conditions including depression. Among the herbals is hypericum or St. John's wort, promoted as having antidepressant effects. Adverse drug interactions have been reported between St. John's wort and drugs used to treat HIV infections as well as those used to reduce the risk of organ transplant rejection. In general, preparations of St. John's wort vary significantly. No adequate studies have been done to determine the antidepressant efficacy of the herbal. Consequently, the NIMH has co-sponsored the first large-scale, multi-site, controlled study of St. John's wort as a potential treatment for depression. Results from this study are expected in 2001.

The Future of NIMH Depression Research

Research on the causes, treatment, and prevention of all forms of depression will remain a high NIMH priority for the foreseeable future. Areas of interest and opportunity include the following:

• NIMH researchers will seek to identify distinct subtypes of depression characterized by various features including genetic risk, course of illness, and clinical symptoms. The aims of this research will be to enhance clinical prediction of onset, recurrence, and co-occurring illness; to identify the influence of environmental stressors in people with genetic vulnerability for major depression; and to prevent the development of co-occurring physical illnesses and substance use disorders in people with primary recurrent depression.

• Because many adult mental disorders originate in childhood, studies of development over time that uncover the complex interactions among psychological, social, and biological events are needed to track the persistence, chronicity, and pathways into and out of disorders in childhood and adolescence. Information about behavioral continuities that may exist between specific dimensions of child temperament and child mental disorder, including depression, may make it possible to ward off adult psychiatric disorders.

• Recent research on thought processes that has provided insights into the nature and causes of mental illness creates opportunities for improving prevention and treatment. Among the important findings of this research is evidence that points to the role of negative attentional and memory biases - selective attention to and memory of negative information - in producing and sustaining depression and anxiety. Future studies are needed to obtain a more precise account of the content and life course development of these biases, including their interaction with social and emotional processes, and their neural influences and effects.

• Advances in neurobiology and brain imaging technology now make it possible to see clearer linkages between research findings from different domains of emotion and mood. Such "maps" of depression will inform understanding of brain development, effective treatments, and the basis for depression in children and adults. In adult populations, charting physiological changes involved in emotion during aging will shed light on mood disorders in the elderly, as well as the psychological and physiological effects of bereavement.

• An important long-term goal of NIMH depression research is to identify simple biological markers of depression that, for example, could be detected in blood or with brain imaging. In theory, biological markers would reveal the specific depression profile of each patient and would allow psychiatrists to select treatments known to be most effective for each profile. Although such data-driven interventions can only be imagined today, NIMH already is investing in multiple research strategies to lay the groundwork for tomorrow's discoveries.

The Broad NIMH Research Program

In addition to studying depression, NIMH supports and conducts a broad based, multidisciplinary program of scientific inquiry aimed at improving the diagnosis, prevention, and treatment of other mental disorders. These conditions include bipolar disorder, clinical depression, and schizophrenia.

Increasingly, the public as well as health care professionals are recognizing these disorders as real and treatable medical illnesses of the brain. Still, more research is needed to examine in greater depth the relationships among genetic, behavioral, developmental, social and other factors to find the causes of these illnesses. NIMH is meeting this need through a series of research initiatives.

• NIMH Human Genetics Initiative

  This project has compiled the world's largest registry of families affected by schizophrenia, bipolar disorder, and Alzheimer's disease. Scientists are able to examine the genetic material of these family members with the aim of pinpointing genes involved in the diseases.

• Human Brain Project

  This multi-agency effort is using state-of-the-art computer science technologies to organize the immense amount of data being generated through neuroscience and related disciplines, and to make this information readily accessible for simultaneous study by interested researchers.

• Prevention Research Initiative

  Prevention efforts seek to understand the development and expression of mental illness throughout life so that appropriate interventions can be found and applied at multiple points during the course of illness. Recent advances in biomedical, behavioral, and cognitive sciences have led NIMH to formulate a new plan that marries these sciences to prevention efforts.

While the definition of prevention will broaden, the aims of research will become more precise and targeted.

next: What To Do When An Employee Is Depressed
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teenage sex

Quote About Parenting:

"I wouldn't know what is most helpful when parents talk about sex. My parents never talked to me, that's why I am now a dad."

Talking to your children about love, intimacy, and sex is an important part of parenting. Parents can be very helpful by creating a comfortable atmosphere in which to talk to their children about these issues. However, many parents avoid or postpone the discussion.

Each year about one million teenage girls become pregnant in the United States and three million teens get a sexually transmitted disease. Children and adolescents need input and guidance from parents to help them make healthy and appropriate decisions regarding their sexual behavior since they can be confused and overstimulated by what they see and hear. Information about sex obtained by children from the Internet can often be inaccurate and/or inappropriate.

Talking about sex may be uncomfortable for both parents and children. Parents should respond to the needs and curiosity level of their individual child, offering no more or less information than their child is asking for and is able to understand. Getting advice from a clergyman, pediatrician, family physician, or other health professional may be helpful. Books that use illustrations or diagrams may aid communication and understanding.

Children have different levels of curiosity and understanding depending upon their age and level of maturity. As children grow older, they will often ask for more details about sex. Many children have their own words for body parts. It is important to find out words they know and are comfortable with to make talking with them easier. A 5-year-old may be happy with the simple answer that babies come from a seed that grows in a special place inside the mother. Dad helps when his seed combines with mom's seed which causes the baby to start to grow. An 8-year-old may want to know how dad's seed gets to mom's seed. Parents may want to talk about dad's seed (or sperm) coming from his penis and combining with mom's seed (or egg) in her uterus. Then the baby grows in the safety of mom's uterus for nine months until it is strong enough to be born. An 11-year-old may want to know even more and parents can help by talking about how a man and woman fall in love and then may decide to have sex.

It is important to talk about the responsibilities and consequences that come from being sexually active. Pregnancy, sexually transmitted diseases, and feelings about sex are important issues to be discussed. Talking to your children can help them make the decisions that are best for them without feeling pressured to do something before they are ready. Helping children understand that these are decisions that require maturity and responsibility will increase the chance that they make good choices.

Adolescents are able to talk about lovemaking and sex in terms of dating and relationships. They may need help dealing with the intensity of their own sexual feelings, confusion regarding their sexual identity, and sexual behavior in a relationship. Concerns regarding masturbation, menstruation, contraception, pregnancy, and sexually transmitted diseases are common. Some adolescents also struggle with conflicts around family, religious or cultural values. Open communication and accurate information from parents increases the chance that teens will postpone sex and will use appropriate methods of birth control once they begin.

In talking with your child or adolescent, it is helpful to:

• Encourage your child to talk and ask questions.
• Maintain a calm and non-critical atmosphere for discussions.
• Use words that are understandable and comfortable.
• Try to determine your child's level of knowledge and understanding.
• Keep your sense of humor and don't be afraid to talk about your own discomfort.
• Relate sex to love, intimacy, caring, and respect for oneself and one's partner.
• Be open in sharing your values and concerns.
• Discuss the importance of responsibility for choices and decisions.
• Help your child to consider the pros and cons of choices.

By developing open, honest and ongoing communication about responsibility, sex, and choice, parents can help their youngsters learn about sex in a healthy and positive manner.

next: Sexual Abuse and Coercion