Posts tagged mental
Posts tagged mental
These dangerous medications are prescribed at an alarming rate without the patient’s consent
When Patricia Thomas, 79, went into a Ventura, Calif.,nursing home with a broken pelvis, the only prescriptions she used were for blood pressure and cholesterol, and an inhaler for her pulmonary disease. By the time she was discharged 18 days later, she “wasn’t my mother anymore,” says Kathi Levine, 57, of Carpinteria, Calif. “She was withdrawn, slumped in a wheelchair with her head down, chewing on her hand, her speech garbled.” Within weeks, she was dead.
Thomas, a former executive assistant, had been given so many heavy-duty medications, including illegally administered antipsychotics, by the Ventura Convalescent Hospital in November of 2010 that she could no longer function. If one drug caused sleeplessness and anxiety, she was given a different medication to counteract those side effects. If yet another drug induced agitation or the urge to constantly move, she was medicated again for that.
"Yes, my mom had Alzheimer’s, but she wasn’t out of it when she went into the nursing home. She could dress and feed herself, walk on her own. You could have a conversation with her,” says Levine. “My mother went into Ventura for physical therapy. Instead, she was drugged up to make her submissive. I believe that my mother died because profit and greed were more important than people.”
A Ventura County Superior Court judge agreed that Levine had a legitimate complaint against the nursing home. In May, attorneys from the law firm Johnson Moore in Thousand Oaks, Calif., joined by lawyers from AARP Foundation, agreed to a settlement in an unprecedented class-action suit against the facility for using powerful and dangerous drugs without the informed consent of residents or family members. “It is the first case of its kind in the country, and hopefully we can replicate this nationwide,” says attorney Kelly Bagby, senior counsel for AARP Foundation Litigation.
A national problem
Tragically, what happened to Patricia Thomas is not an isolated incident. According to Charlene Harrington, professor of nursing and sociology at the University of California, San Francisco, as many as 1 in 5 patients in the nation’s 15,500 nursing homes are given antipsychotic drugs that are not only unnecessary, but also extremely dangerous for older patients. The problem, experts say, stems from inadequate training and chronic understaffing, as well as an aggressive push by pharmaceutical companies to market their products.
"The misuse of antipsychotic drugs as chemical restraints is one of the most common and long-standing, but preventable, practices causing serious harm to nursing home residents today," says Toby Edelman, an attorney at the Center for Medicare Advocacy in Washington, D.C. "When nursing facilities divert funds from the care of residents to corporate overhead and profits, the human toll is enormous."
Kickbacks to doctors
Last November, in what the U.S. Department of Justice called “one of the largest health care fraud settlements in U.S. history,” Johnson & Johnson and its subsidiaries were fined more than $2.2 billion to resolve criminal and civil charges because of their aggressive marketing of drugs, including antipsychotics, to nursing homes, when they knew the drugs had not been approved by the U.S. Food and Drug Administration (FDA) as safe and effective for a general elderly population. The corporation also allegedly paid kickbacks to physicians, as well as to Omnicare, the nation’s largest long-term-care pharmacy provider. Omnicare pharmacists were recommending Johnson & Johnson’s drugs, including the antipsychotic Risperdal, for use by nursing home residents.
Back in 2009, Eli Lilly did the same thing with its antipsychotic Zyprexa, marketing to older people in nursing homes and assisted living facilities, federal prosecutors charged. In a settlement, the company agreed to pay $1.4 billion. “This case should serve as still another warning to all those who break the law in order to improve their profits,” Patrick Doyle, special agent in charge of the Office of Inspector General for the U.S. Department of Health and Human Services in Philadelphia, said at the time.A report released in March by the inspector general of Health and Human Services charged that one-third of Medicare patients in nursing homes suffered harm, much of which was preventable. “Too many nursing homes fail to comply with federal regulations designed to prevent overmedication, giving patients antipsychotic drugs in ways that violate federal standards for unnecessary drug use,” Inspector General Daniel Levinson said. “Government, taxpayers, nursing home residents, as well as their families and caregivers, should be outraged — and seek solutions.”Antipsychotic drugs are intended for people with severe mental illness, such as patients with schizophrenia or bipolar disorder. As such, they carry the FDA’s black-box warning that they are not intended for frail older people or patients with Alzheimer’s or dementia. In those populations, these drugs can trigger agitation, anxiety, confusion, disorientation and even death. “They can dull a patient’s memory, sap their personalities and crush their spirits,” according to a report from the California Advocates for Nursing Home Reform.
Kept in the dark
What’s more, the law requires “informed consent” by a patient or, if that is no longer possible, by his or her family before such drugs are administered. Yet advocates say that, all too frequently, this doesn’t happen. Levine, for example, says she didn’t know about all her mother’s medications until she transferred her mom to another facility. “When I saw the list of what she’d been given, I freaked out. I was upset and angry, in tears,” she recalls.
How can such things happen? One explanation is that many facilities don’t have enough properly trained staff: Most of the patient care in nursing homes falls to certified nursing assistants (CNAs) who need as little as 75 hours of on-the-job training to get certified. “Yet if you want a license to be a hairdresser, you need 1,500 hours of training,” Harrington points out.What’s more, CNAs are paid low wages so many of them work long hours. “They are totally exhausted, with extremely heavy workloads,” she says. That leads to high employee turnover and caregivers who don’t know their patients well enough to recognize their needs.Compounding the problem, many nursing home patients require a high level of care. Some are incontinent, and an estimated 60 to 70 percent have some form of dementia. There should be one CNA for every seven patients, but in some cases, the ratio is 1 to 15 — or even more, Harrington says. There also tend to be too few physicians actually present in nursing homes. “These facilities are highly medicalized, but doctors are rarely there,” says Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform. He says that because of their low rate of reimbursement from Medicare, nursing homes are too often seen as a place where few top doctors practice.The result of all this can be so-called behavior problems among patients — which is the explanation nursing homes cite for giving patients unnecessary antipsychotic drugs, according to the U.S. Centers for Medicare and Medicaid Services (CMS). And pharmaceutical companies have been aggressively marketing their products as an easy and effective way to control these issues.
"There was a push by drug manufacturers, claiming these medications work for seniors when they knew, in fact, that it doubled their risk of death," Chicotel says.
CMS, which oversees the nursing homes that receive funding from federal programs, says it has been working to correct deficiencies in nursing facilities, including the inappropriate use of medications. The agency achieved the goal of reducing the inappropriate use of antipsychotic drugs by 15 percent over a recent two-year period, and hopes to get to a 30 percent reduction in the next few years, according to spokesman Thomas Hamilton. But Edelman points out that initial goal was reached more than a year late, and some 300,000 patients are still receiving the drugs inappropriately. Hamilton acknowledges that more needs to be done, but lack of funding from Congress is making even the most preliminary work difficult.
A better way
Fortunately, a growing number of nursing homes have begun to look for more effective — and more humane — ways to care for patients. Better training for caregivers is key: According to Cheryl Phillips, M.D., a geriatrician at LeadingAge, an organization representing nonprofit services for older people, nursing home staff can be trained to deal with behavior issues thoughtfully and creatively, without resorting to drugs.
She cites an example of a male patient who was spending his days in a noisy nursing home activity room. One day, he grew more and more agitated and tripped an aide with his cane. To calm him down, the staff took him to his private quarters. Over the following days, his behavior in the activity room became increasingly aggressive; he began randomly hitting caregivers and fellow patients. Each time, he was taken away to spend time in his room.
"The staff initially thought he had become violent and needed an antipsychotic," Phillips recalls. "But they ultimately realized that the cacophony in the activity room was stressing him out. Caregivers inadvertently rewarded him by giving him quiet time in his room, which is what he wanted. When they did it repetitively, they reinforced his aggressive behavior." Once the staff discussed the problem and began finding peaceful activities for the patient, the problem was solved — no drugs needed.
Putting patients first
Another success story is the Beatitudes facility in Phoenix, which dramatically changed its way of handling patients with dementia based on Tom Kitwood’s book Dementia Care Reconsidered: The Person Comes First. “What happens here is not for our systems, our convenience, but for the people we care for,” says Tena Alonzo, the director of education and research at Beatitudes. “People with dementia have disturbances in their sleep/wake cycle, so we let them be comfortable and decide when they want to sleep or eat, or not. Or how they want to spend their time,” she says. As a result, patients stop resisting care, and the facility runs more smoothly.
The Beatitudes’ philosophy is now being taught to a growing number of nursing homes around the country. “We’ve created a softer, gentler approach, acknowledging that we are not in charge of a person’s life — they are. In allowing them to retain their dignity, and adopt a comfort level of care, we’ve had better outcomes,” says Alonzo. That paradigm shift has not increased operating expenses, or required a higher staff-to-resident ratio. “We discovered that better care was better business,” Alonzo says.
For Kathi Levine and her mother, these encouraging developments are coming too late. “I want our lawsuits to impact nursing homes all over the country,” Levine says. “We need to protect our family members. They don’t have a voice, they can’t speak for themselves. So we need to speak out for them and help other people know what to look for. I want to make sure that what happened to my family doesn’t happen to anyone else.”
Jan Goodwin is an award-winning author and investigative journalist for national publications.
Rikers: Where Mental Illness Meets Brutality in Jail
By Michael Winerip and Michael Schwirtz, The New York Times
Just a few weeks earlier, Andre Lane was locked in solitary confinement in a Rikers cellblock reserved for inmates with mental illnesses when he became angry at the guards for not giving him his dinner and splashed them with either water or urine. Correction officers handcuffed him to a gurney and transported him to a clinic examination room beyond the range of video cameras where, witnesses say, several guards beat him as members of the medical staff begged for them to stop. The next morning, the walls and cabinets of the examination room were still stained with Mr. Lane’s blood.
The assaults on Mr. Bautista and Mr. Lane were not isolated episodes. Brutal attacks by correction officers on inmates — particularly those with mental health issues — are common occurrences inside Rikers, the country’s second-largest jail, a four-month investigation by The New York Times found.
Reports of such abuses have seldom reached the outside world, even as alarm has grown this year over conditions at the sprawling jail complex. A dearth of whistle-blowers, coupled with the reluctance of the city’s Department of Correction to acknowledge the problem and the fact that guards are rarely punished, has kept the full extent of the violence hidden from public view.
But The Times uncovered details on scores of assaults through interviews with current and former inmates, correction officers and mental health clinicians at the jail, and by reviewing hundreds of pages of legal, investigative and jail records. Among the documents obtained by The Times was a secret internal study completed this year by the city’s Department of Health and Mental Hygiene, which handles medical care at Rikers, on violence by officers. The report helps lay bare the culture of brutality on the island and makes clear that it is inmates with mental illnesses who absorb the overwhelming brunt of the violence.
The study, which the health department refused to release under the state’s Freedom of Information Law, found that over an 11-month period last year, 129 inmates suffered “serious injuries” — ones beyond the capacity of doctors at the jail’s clinics to treat — in altercations with correction department staff members.
The report cataloged in exacting detail the severity of injuries suffered by inmates: fractures, wounds requiring stitches, head injuries and the like. But it also explored who the victims were. Most significantly, 77 percent of the seriously injured inmates had received a mental illness diagnosis.
Novel ‘Avatar Therapy’ May Silence Voices in Schizophrenia
By Deborah Brauser, Medscape Medical News
A novel treatment may help patients with schizophrenia confront and even silence the internal persecutory voices they hear, new research suggests.
Avatar therapy allows patients to choose a digital face (or “avatar”) that best resembles what they picture their phantom voice to look like. Then, after discussing ahead of time the things the voice often says to the patient, a therapist sits in a separate room and “talks” through the animated avatar shown on a computer monitor in a disguised and filtered voice as it interacts with the patient.
In addition, the therapist can also talk by microphone in a normal voice to coach the patient throughout each session.
In a pilot study of 26 patients with treatment-resistant psychosis who reported auditory hallucinations, those who received 6 half-hour sessions of avatar therapy reported a significant reduction in the frequency and volume of the internal voices ― and 3 reported that the voices had disappeared altogether.
"Opening up a dialogue between a patient and the voice they’ve been hearing is powerful. This is a way to talk to it instead of only hearing 1-way conversations," lead author and creator of the therapy program Julian Leff, MD, FRCPsych, emeritus professor at the Institute of Psychiatry in London, told meeting attendees.
"As the therapist, I’m sharing the patient’s experience and can actually hear what the patient hears. But it’s important to remind them that this is something that they created and that they are in a safe space," Dr. Leff told Medscape Medical News after his presentation.
Two presentations were given here at the International Congress of the Royal College of Psychiatrists (RCPsych) 2014 the day after the study results were released in the print edition of Psychosis.
According to the investigators, 1 in 4 people who hear phantom voices fail to respond to antipsychotic medication.
Dr. Leff explained that this program started a little more than 3 years ago, after he had retired “and could start thinking clearly again.” He had been interested in the phenomenon of phantom voices for more than 40 years.
"Our mind craves meaningful input. That’s its nourishment. And if it’s deprived of nourishment, it pushes out something into the outside world," he said. "The aim of our therapy is to give the patient’s ego back its mastery over lost provinces of his mental life."
The researchers used the “off-shelf programs” Facegen for the creation of the avatar faces and Annosoft LIP-SYNC for animating the lips and mouth. They also used a novel real-time voice-morphing program for the voice matching and to let the voice of a therapist to be changed.
In fact, Dr. Leff reported that one option the program provided changed his voice into that of a woman.
After a patient chose a face/avatar from among several options, the investigators could change that face. For example, 1 patient spoke of hearing an angel talk to him but also talked about wanting to live in a world of angels. So the researchers made the avatar very stern and grim so that the patient would be more willing to confront it.
Another patient chose a “red devil” avatar and a low, booming voice to represent the aggressiveness that he had been hearing for 16 years.
For the study, 26 participants between the ages of 14 and 74 years (mean age, 37.7 years; 63% men) were selected and randomly assigned to receive either avatar therapy or treatment as usual with antipsychotic medication.
The length of time for hearing voices ranged from 3.5 years to more than 30 years, and all of the patients had very low self-esteem. Those who heard more than 1 voice were told to choose the one that was most dominant.
During the sessions, the therapist sat in a separate room and played dual roles. He coached the participants on how to confront and talk with the avatars in his own voice, and he also voiced the avatars. All of the sessions were recorded and given to the participants on an MP3 recorder to play back if needed, to remind the patients how to confront and talk to the auditory hallucination if it reappeared.
"We told them: It’s like having a therapist in your pocket. Use it," said Dr. Leff.
All of the avatars started out appearing very stern; they talked loudly and said horrible things to match what the patients had been reportedly experiencing. But after patients learned to talk back to the faces in more confident tones, the avatars began to “soften up” and discuss issues rationally and even offer advice.
Most of the participants who received avatar therapy went on after the study to be able to start new jobs. In addition, most reported that the voices went down to whispers, and 3 patients reported that the voices stopped completely.
The patient who confronted the red devil avatar reported that the voice had disappeared after 2 sessions. At the 3-month follow-up, he reported that the voice had returned, although at night only; he was told to go to bed earlier (to fight possible fatigue) and to use the MP3 player immediately beforehand. On all subsequent follow-ups, he reported that the voice was completely gone, and he has since gone on to work abroad.
Another patient who reported past experiences of abuse asked that his avatar be created wearing sunglasses because he could not bear to look at its eyes. During his sessions, Dr. Leff told him through the avatar that what had happened to the patient was not his fault. And at the end of 5 sessions, the phantom voice disappeared altogether.
Although 1 female patient reported that her phantom voice had not gone away, it had gotten much quieter. “When we asked her why, she said, ‘The voice now knows that if it talks to me, I’ll talk back,’ ” said Dr. Leff.
"These people are giving a face to an incredibly destructive force in their mind. Giving them control to create the avatar lets them control the situation and even make friends with it," he added.
"The moment that a patient says something and the avatar responds differently than before, everything changes."
In addition, there was a significant reduction in depression scores on the Calgary Depression Scale for Schizophrenia and in suicidal ideation for the avatar participants at the 3-month follow-up assessment.
A bigger study with a proposed sample size of 140 is currently under way and is “about a quarter of the way complete,” Dr. Leff reports. Of these patients, 70 will receive avatar therapy, and 70 will receive supportive counseling.
"In order for others to master this therapy, it is necessary to construct a treatment manual and this has now been completed, in preparation for the replication study," write the investigators.
"One of its main aims is to determine whether clinicians working in a standard setting can be trained to achieve results comparable to those that emerged from the pilot study," they add.
"Fascinating" New Therapy
"I think this is really exciting. It’s a fascinating, new form of therapy," session moderator Sridevi Kalidindi, FRCPsych, consultant psychiatrist and clinical lead in rehabilitation at South London and Maudsley NHS Foundation Trust in the United Kingdom, told Medscape Medical News.
"I think it is a novel way of approaching these very challenging symptoms that people have. From the early results that have been presented, it provides hope for people that they may actually be able to improve from all of these symptoms. And we may be able to reduce their distress in quite a different way from anything we’ve ever done before."
Dr. Kalidindi, who is also chair of the Rehabilitation Faculty for the Royal College of Psychiatrists, was not involved with this research.
She added that she will be watching this ongoing program “with great interest.”
"I was very enthused to learn that more research is going on with this particularly complex group," said Dr. Kalidindi.
"This could be something for people who have perhaps not benefitted from other types of intervention. Overall, it’s fantastic."
International Congress of the Royal College of Psychiatrists (RCPsych) 2014. Presented in 2 oral sessions on June 26, 2014.
Psychosis. 2014;6:166-176. Full text
[I]f I return to office life, I for one will be open about having experienced depression. The more open we are, the more we can find ways to help those who suffer to help themselves. We will be able to introduce work practices that will help reduce anxiety and depression happening in the first place.
When I returned to work after suffering my first depressive episode, I shared very little of what had happened with colleagues. At the time, I was a reporter in The Times newsroom in London. My husband was a junior banker at Goldman Sachs who had just stood as a Conservative candidate in the 1997 election that saw Tony Blair returned with a landslide victory.
I was swayed by stigma: I found it difficult to tell my colleagues that I had been depressed. Partly this was because I myself found it hard to accept that I had suffered from mental ill health, even though I had been sufficiently unwell to go to a psychiatric hospital.
I had very little to be obviously depressed about. We were young, blessed with good jobs and two small children. I did not consider myself unhappy, though I was an anxious person struggling to balance our two professional careers and two small children. But I was also ambitious and I did not think admitting to depression would help my career prospects.
It was only seven years later, when I suffered a second breakdown even worse than the first, that I began to be more open about it. You might say that by then I had less to lose: I had left The Times a few years earlier and become a freelance journalist. But I still found it hard to admit to this illness.
My own forthrightness second time around allowed others with similar professional lives to reveal the anxiety they routinely experienced – while exhorting me not to tell others. One former colleague admitted to having such high levels of anxiety that he would routinely vomit ahead of attending the newsroom conference. But he never breathed a word.
An underlying predisposition to depression may be exacerbated by the stress and relentless hard work it can take to be supposedly successful. Britons work the longest hours in Europe, with the equivalent of 40 days of unpaid overtime a year, according to the National Health Service. The recession, short-term contracts and the sheer pace of the 24/7 digital world have all added to pressure in the professional workplace and made it a fertile breeding ground for depression.
In my case, my own over-sensitive nature combined with an attempt to be a career girl, a mother and a supportive wife, had twice led to a debilitating sense of being overwhelmed and illness.
Why then is the stigma around suffering from anxiety and depression still so prevalent? The most common reaction to my memoir about my battle with depression has been “you’re very brave” in an ironic, “not a good idea” manner.
Part of the answer I think is that while depression is an illness, with at times harrowing physical symptoms, the truth is more nuanced. Our behaviour can affect our mood. When I suffered from depression, there were times when I could have roused myself if I had really tried. What ended up working for me included therapy; relaxation and breathing exercises; and poetry, which helps me stop worrying by forcing me into the moment.
The link between behaviour and mood also explains why workplace colleagues may be less sympathetic than if someone was suffering from diabetes or cancer, for example. When they believe you could pull yourself together, in some cases they may be right.
Yet in other cases of clinical depression, such an attitude is laughable. I was unable even to get from my bedroom to the bathroom. Saying you feel depressed can cover a spectrum from someone feeling gloomy to utterly suicidal.
I think the second explanation for the continuing stigma is that depression is frightening. The sense that we are mad, that we have lost our minds, or our brains have gone wrong in some sense, is so terrifying that many sufferers would rather keep quiet.
Yet if I return to office life, I for one will be open about having experienced depression. The more open we are, the more we can find ways to help those who suffer to help themselves. We will be able to introduce work practices that will help reduce anxiety and depression happening in the first place. And ultimately, we will become less frightened of an illness that one in five will experience at some point in their lives.
The writer is the author of ‘Black Rainbow: how words healed me – my journey through depression’. Michael Skapinker is away
The case against labeling and medicating children, and effective alternatives for treating them.
In the United States, at least 9% of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5%. How come the epidemic of ADHD—which has become firmly established in the United States—has almost completely passed over children in France?
Is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the United States. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological—psycho stimulant medications such as Ritalin and Adderall.
French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children’s focusing and behavioral problems withdrugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child’s brain but in the child’s social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child’s brain.
French child psychiatrists don’t use the same system of classification of childhood emotional problems as American psychiatrists. They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM. According to Sociologist Manuel Vallee, the French Federation of Psychiatry developed an alternative classification system as a resistance to the influence of the DSM-3. This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L’Enfant et de L’Adolescent), first released in 1983, and updated in 1988 and 2000. The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children’s symptoms, not on finding the best pharmacological bandaids with which to mask symptoms.
To the extent that French clinicians are successful at finding and repairing what has gone awry in the child’s social context, fewer children qualify for the ADHD diagnosis. Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to “pathologize” much of what is normal childhood behavior. The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.
The French holistic, psychosocial approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child’s problem. In the United States, the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children’s behavior.
And then, of course, there are the vastly different philosophies of child-rearing in the United States and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé. I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the United States.
From the time their children are born, French parents provide them with a firm cadre—the word means “frame” or “structure.” Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it. French babies, too, are expected to conform to limits set by parents and not by their crying selves. French parents let their babies “cry it out” if they are not sleeping through the night at the age of four months.
French parents, Druckerman observes, love their children just as much as American parents. They give them piano lessons, take them to sports practice, and encourage them to make the most of their talents. But French parents have a different philosophy of discipline. Consistently enforced limits, in the French view, make children feel safe and secure. Clear limits, they believe, actually make a child feel happier and safer—something that is congruent with my own experience as both a therapist and a parent. Finally, French parents believe that hearing the word “no” rescues children from the “tyranny of their own desires.” And spanking, when used judiciously, is not considered child abuse in France. (Author’s note: I am not personally in favor of spanking children).
As a therapist who works with children, it makes perfect sense to me that French children don’t need medications to control their behavior because they learn self-control early in their lives. The children grow up in families in which the rules are well-understood, and a clear family hierarchy is firmly in place. In French families, as Druckerman describes them, parents are firmly in charge of their kids—instead of the American family style, in which the situation is all too often vice versa.
Copyright © Marilyn Wedge, Ph.D.
Marilyn Wedge is the author of Pills Are Not for Preschoolers: A Drug-Free Approach for Troubled Kids.