What is health care reform?

Organization and Function

The function of health care is to provide preventive diagnostic treatment and emergency care for the citizens of a country. The physical organization of the health care system in the United States consists of hospitals, outpatient clinics, pharmacies, home health care services, long-term care facilities, public health clinics, and other supportive services such as occupational therapy. There are many layers of staff including physicians, nurses, physician assistants, other medical support staff, office staff, and administrative staff. These organizations are regulated by state and federal agencies. Naturopathic, dental, optometric, and other services are sometimes excluded from health insurance or health care plans ,or these services sometimes offer separate insurance policies and programs.

Health Care in the United States

There are many misconceptions about the existing health care systems in North America and around the world. In the United States, access to healthcare services and direct cost to patients depend on an the patient's insurance plan or lack of insurance plan. The United States does not have universal health care, which covers every individual in a nation regardless of income level. Rather, many employers pay part or all of the health insurance costs for their employees. Working individuals whose employers do not pay health insurance costs buy insurance out-of-pocket. People who are unemployed or who cannot afford to purchase health insurance are sometimes eligible for free or low-cost insurance through various government programs such as Medicare and Medicaid.

Depending on the insurance plan offered, copayments may be due at the time of service, and certain services may not be offered or covered by the insurance. For the millions of people who have no insurance, the health care system is a purely fee-for-service system like that found in developing countries. Some are able to navigate and take advantage of a patchwork of government services such as state-run plans or county hospitals may pay for emergency care. The United States is one of the few developed countries without universal access to health care, and since access to health care is inextricably tied to access to affordable health insurance, many see the system as failing the American people. Historically there have been disparities in availability of health care for people from various income levels, and the care that is available is not of consistent quality. Immigrants, the poor, and the homeless seem to be most affected by inaccessibility to health care, and seniors and children are also vulnerable. Many feel that the United States has had one system for those who can afford health insurance, and thus quality health care, and another system, often of lesser quality, for those without insurance. The Affordable Care Act of 2010 was an attempt to make quality health care accessible to all US citizens.

The Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA) of 2010—commonly called the Affordable Care Act (ACA) or Obamacare, after its major backer, US president Barack Obama—sought to reform a number of aspects of the US health insurance industry, as well as improve the access to and quality of health care services. Since the passage of the ACA, insurers have been required to cover preventive services without a deductible, copayment, or other out-of-pocket expense; extend coverage to children with existing medical conditions; cover young-adult children up to age twenty-six on their parents’ plans; spend most of their premiums on benefits to consumers rather than on administrative costs; and provide justification for rate increases. Starting in 2014, insurers were no longer allowed to set annual dollar limits on coverage, reject anyone based on preexisting medical conditions, discriminate against women, or restrict or deny coverage to those who participate in clinical trials. The ACA also expanded Medicare coverage and benefits through the state governments, and issues of substandard health care for children would be addressed by increasing Medicaid payment rates to health care providers to help ensure access to primary care providers for more low-income children. Children would also no longer be denied coverage for preexisting conditions and would no longer have annual or lifetime caps placed on their health insurance. For very poor or uninsured families, the ACA provided tax credits and vouchers to help with quality health insurance coverage.

At the time of its passage, the Affordable Care Act was the most substantial overhaul of the US healthcare system since the passage of the Medicare and Medicaid amendments during the Johnson administration in the mid-1960s. Despite facing intense opposition from the general public, medical professionals, and various public officials and numerous problems and glitches in its start-up, many still had hope that the ACA would dramatically improve the affordability of and access to health insurance and quality health care.

Services and Cost

There is a balance between the services provided by any system, the cost per service, and the reimbursement of the provider. The provision of health care varies from simple procedures such as suturing a wound to very complex care such as diagnosing a rare neurologic disorder. Cost will also increase with the time a provider spends with a patient. In systems that have a fixed cost per service, the provider will have a financial incentive to see as many patients as quickly as possible. Malpractice insurance costs and claims also may affect cost and services. In some cases, tests or treatments may be recommended in order to reduce chances of malpractice claims. Some providers will discontinue high-risk procedures because of malpractice insurance costs.

It is a complex equation to determine this balance of service to patients; cost to patients via insurance, taxes, or cash; and reimbursement to providers. Geography and ethnic diversity will also complicate the equation. In 2012, the population of the United States was more than 313 million, Canada was almost 35 million, and Sweden was about 9.5 million. The United States covers about 3.7 million square miles, Canada about 3.8 million square miles, and Sweden about 170,000 square miles. These factors will influence the feasibility of services in some cases. For example, in sparsely populated areas of any country, it is difficult to provide the same services that may be available in a more densely populated metropolitan areas or in major cities.

Cost is also influenced by insurance company profits, health care provider reimbursement, technology, and preventive care. Some health care systems attempt to limit overall costs by providing preventive education and care. Immunization programs are an example of preventive health care that can reduce illness and therefore reduce cost to the system. Other systems use government control such as rationing to control costs.

Rationing, or "prioritizing," health care invariably involves financial considerations, but it can also involve scheduling, medicinal, and technological factors. Countries that feature universal health care frequently ration technological resources and attempt to secure bargaining arrangements with drug suppliers in order to purchase bulk amounts at a lower rate. In the United States, medical resources are more commonly rationed through administrative managed care organizations such as HMOs (health maintenance organizations); this form is sometimes termed "explicit rationing." The general theory behind rationing is that reducing less-necessary treatment allows individuals suffering from more serious conditions to receive treatment. The "implicit rationing" practiced in Britain is less formally defined and is intended to balance cost and medical need. Rationing may also lead to long waiting lists for services. Insurance companies generally try not to ration resources but rather screen high-risk candidates for policies and impose high deductibles to discourage the use of policies for less-serious treatment

The balance between services and cost is at the core of any health care reform debate. This balance is influenced by decisions such as preventive care provisions, what is considered to be elective care versus necessary care, individual needs versus the needs of the population, long-term care provision, and a host of other factors.

Perspective and Prospects

People with steady employment with health care benefits will not necessarily perceive that there is any problem with the existing system. A portion of the millions of uninsured Americans may also not perceive a problem if they have not had a need to access services. However, those uninsured with serious health issues or those who become unemployed and lost their insurance may feel there is a need for reform.

In spite of leading in health care expenditure, the United States places low in many rankings of health indicators. Some use these statistics to point to the need for health care reform in the United States. According to the World Health Organization (WHO), average life expectancy at birth for Americans was 79 years in 2011; the country ranks below numerous industrialized nations, including Japan, France, and Israel. Life expectancy may be affected by other factors such as homicide, so some believe this is not a true indicator of the quality of health care. Other indicators are similarly complex.

Health care reform in the United States is a particularly difficult task due to the large population, the variety of health care delivery systems that exist, and the many diseases and other health concerns that must be treated.. Chronic diseases such as heart disease, mental illness, substance use disorder, asthma, and diabetes account for a large amount of spending. Some politicians and health care professionals believe that early intervention in these cases would ultimately save money. Reform that includes more access to care, preventive care, and early intervention for people with these chronic diseases may improve health quality while decreasing health costs.

There are several things to consider regarding health care reform in the United States. It comes down to the collective philosophy of the citizens, the financial assessment of the benefit of investing in care for the underserved populations, the cost to the citizens through taxation, the cost to citizens for poor health in a segment of the population, and the cost to businesses for employee insurance.

Points under debate include whether providing insurance and preventive care to the currently uninsured might save money, as such individuals might otherwise access costly emergency care when untreated preexisting conditions lead to more serious illness. Lack of affordable insurance may discourage people from becoming self-employed or may cause small businesses to hire only part-time employees to avoid having to pay for expensive employee insurance plans.

Philosophical issues abound as to whether health care is to be considered a fundamental right, and if so, what level of services should be considered and whether wealthier citizens be allowed to purchase faster and more extensive services. The question of whether citizens have a responsibility to have insurance and the role of low-cost insurance as a stimulus to small businesses and self-employed people are other factors to consider. Profit versus nonprofit provision of care, as well as reimbursement for providers, also affects the debate.

Bibliography

Armstrong, Pat, and Hugh Armstrong. About Canada Health Care. Black Point, N.S.: Fernwood, 2008. Print.

Greer, Scott L., and Paulette Kurzer, eds. European Union Public Health Policy: Regional and Global Trends. New York: Routledge, 2013. Print.

Halvorson, George C. Health Care Reform Now! A Prescription for Change. San Francisco: John Wiley & Sons, 2007.

"Health Reform Implementation: What Does It Mean for Children?" Children's Defense Fund. Children's Defense Fund, 2012. Web. 24 Sept. 2014.

Jacobs, Lawrence R., and Theda Skocpol. Health Care Reform and American Politics: What Everyone Needs to Know. Rev. ed. New York: Oxford UP, 2012. Print.

"Key Features of the Affordable Care Act by Year." Health and Human Services. US Dept. of Health and Human Services, n.d. Web. 24 Sept. 2014.

Kominski, Gerald F. Changing the US Health Care System: Key Issues in Health Services Policy and Management. 4th ed. Malden: Wiley-Blackwell, 2013. Print.

Levy, Jena. "US Uninsured Rate Drops to 13.4 Percent." Gallup. Gallup, 5 May 2013. Web. 22 Sept. 2014. Print.

Purnell, Larry D. Transcultural Health Care: A Culturally Competent Approach. Philadelphia: F. A. Davis, 2013. Print.

Reid, T. R. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York: Penguin, 2009. Print.

United States Census Bureau. "Health Insurance." US Department of Commerce, 2011.

Weissert, William G. Governing Health: The Politics of Health Policy. 4th ed. Baltimore: Johns Hopkins University Press, 2012. Print.

What is sleeping pill addiction?

History of Use

Zolpidem (Ambien), a nonbenzodiazepine sleeping aid, was approved as a prescription by the US Food and Drug Administration in 1992. Zapelon (Sonata) was approved in 1999 and eszopiclone (Lunesta) was approved in 2004. Since the introduction of zolpidem, there have been reports of diversion and abuse because of the addictive nature of these medications. When abused, these medications are often combined with alcohol or other sedating drugs, which heightens adverse reactions.

Effects and Potential Risks

Zolpidem, zapelon, and eszopiclone all have mechanisms of action involving the GABA-A receptor within the central nervous system, whereas ramelteon (Rozerem) is a selective agonist of melatonin. Chemically, zolpidem and zapelon bind specifically to a1 subunits on GABA-A receptors.

Generally, these medications are indicated only for short-term management of insomnia and should be ingested only when the patient will get at least seven to eight hours of uninterrupted sleep. However, because of their addictive properties, these medications are often used for extended periods of time. Of the three sleeping medications, the only one that does not include a labeling restriction for short-term use only is eszopiclone. Overall, this medication has less potential for abuse or dependence in most patients.

Common adverse effects of this class of medications include daytime sedation, drowsiness, cognitive impairment, problems with motor coordination, and dependence. Although reported less frequently, more serious complications include sleep-related behaviors such as sleep-walking, sleep-eating, sleep-driving, and temporary amnesia. There also have been reports of worsening depression and suicidal thoughts, so a complete psychological history is an important factor in the decision of what sleeping medication, if any, to prescribe.

Bibliography

Dolder, Christian, Michael Nelson, and Jonathan McKinsey. “Use of Non-Benzodiazepine Hypnotics in the Elderly: Are All Agents the Same?” CNS Drugs 21.5 (2007): 389–405. Print.

Rosenberg, R. P. “Sleep Maintenance Insomnia: Strengths and Weaknesses of Current Pharmacologic Therapies.” Annals of Clinical Psychiatry 18.1 (2006): 49–56. Print.

Wagner, Judy, Mary L. Wagner, and Wayne A. Hening. “Beyond Benzodiazepines: Alternative Pharmacologic Agents for the Treatment of Insomnia.” Annals of Pharmacotherapy 32.6 (1998): 680–91. Print.

Name the precipitate formed when an aqueous solution of sodium sulphate and barium chloride are mixed.

The reacting species are sodium sulfate (Na2SO4) and barium chloride (BaCl2) and the chemical reaction between these species can be written as:

`Na_2SO_4 (aq) + BaCl_2 (aq) -> BaSO_4 (s) + NaCl (aq)`

In this reaction, sodium sulfate reacts with barium chloride, both in aqueous phase, to produce barium sulfate and sodium chloride. 

The above mentioned equation is not balanced, for example, in terms of sodium (1 versus 2 atoms on reactant and product sides)....

The reacting species are sodium sulfate (Na2SO4) and barium chloride (BaCl2) and the chemical reaction between these species can be written as:

`Na_2SO_4 (aq) + BaCl_2 (aq) -> BaSO_4 (s) + NaCl (aq)`

In this reaction, sodium sulfate reacts with barium chloride, both in aqueous phase, to produce barium sulfate and sodium chloride. 

The above mentioned equation is not balanced, for example, in terms of sodium (1 versus 2 atoms on reactant and product sides). The well-balanced chemical equation for this reaction is:

`Na_2SO_4 (aq) + BaCl_2 (aq) -> BaSO_4 (s) + 2 NaCl (aq)`

Here, the only solid is barium sulfate and hence this is the required precipitate of this reaction. 

We can also use this reaction to determine the amount of the precipitate formed when certain amounts of the reactants are used. Using the stoichiometry, 1 mole of sodium sulfate reacts with 1 mole of barium chloride to form 1 mole of barium sulfate precipitate and 2 moles of sodium chloride.

Hope this helps. 

How does Nick begin to put his plan into action in Andrew Clements' Frindle?

In Andrew Clements' Frindle, as soon as Nick decides to take the meanings of words into his own hands by inventing his own word for the word pen, Nick knows his next step is to get other people to use it. Just as Mrs. Granger states, a word doesn't have a meaning unless society agrees about the word's meaning; therefore, Nick knows that he must get other people to agreethat a pen...

In Andrew Clements' Frindle, as soon as Nick decides to take the meanings of words into his own hands by inventing his own word for the word pen, Nick knows his next step is to get other people to use it. Just as Mrs. Granger states, a word doesn't have a meaning unless society agrees about the word's meaning; therefore, Nick knows that he must get other people to agree that a pen is a frindle, not a pen.

The first step to his plan is to go into the Penny Pantry store and ask to purchase a frindle. It takes the woman behind the counter a while to catch on to what he is asking for, but she soon does; he then walks off after having paid 49 cents for a frindle. Next, he recruits his friends to also ask to purchase frindles. On five consecutive days, five of Nick's friends walk into Penny Pantry and ask to purchase frindles: John, Pete, Chris, Dave, and Janet. By the time Janet asks to buy a frindle, the woman behind the counter had become so used to the question that she instantly "reached right for the pens and said, 'Blue or black?'" (p. 35), showing Nick, who was observing from an aisle, that he had already made someone treat the word frindle as a real word. He also asks all five of his friends to take an oath promising to "never use the word PEN again" but to, instead, always "use the word FRINDLE" (p. 35).

The third part of Nick's plan is to use the word in class to get his other classmates to start using it too. He does so by raising his hand and telling Mrs. Granger that he "forgot [his] frindle" (p. 36). Nick's friend John then makes a big show of searching for an extra frindle in his backpack. A fourth part of his plan is to have all of the fifth graders, during their class photo, to say the word frindle, while holding out frindles, instead of the word cheese.

What is cognitive behavior therapy (CBT)?

Introduction

The cognitive behavior therapies are not a single therapeutic approach, but rather a loosely organized collection of therapeutic approaches that share a similar set of assumptions. At their core, cognitive behavior therapies share three fundamental propositions: Cognitive activity affects behavior; cognitive activity may be monitored and altered; and desired behavior change may be effected through cognitive change.

The first of the three fundamental propositions of cognitive behavior therapy suggests that it is not the external situation that determines feelings and behavior, but rather the person’s view or perception
of that external situation that determines feelings and behavior. For example, if a person has failed the first examination of a course, that individual could appraise it as a temporary setback to be overcome or as a horrible loss. Although the situation remains the same, the thinking about that situation is radically different in the two examples cited. Each of these views will lead to significantly different emotions and behaviors.

The third cognitive behavioral assumption suggests that desired behavior change may be effected through cognitive change. Therefore, although cognitive behavior theorists do not reject the notion that rewards and punishment (reinforcement contingencies) can alter behavior, they are more likely to emphasize that there are alternative methods for behavior change, one in particular being cognitive change. Many approaches to therapy fall within the scope of cognitive behavior therapy as it is defined here. Although these approaches share the theoretical assumptions described, a review of the major therapeutic procedures subsumed under the heading of cognitive behavior therapy reveals a diverse amalgam of principles and procedures, representing a variety of theoretical and philosophical perspectives.

Rational Therapies

Rational emotive therapy, developed by psychologist Albert Ellis, is regarded by many as one of the premier examples of the cognitive behavioral approach; it was introduced in the early 1960s. Ellis proposed that many people are made unhappy by their faulty, irrational beliefs, which influence the way they interpret events. The therapist interacts with patients, attempting to direct patients to more positive and realistic views. Cognitive therapy, pioneered by Aaron T. Beck, has been applied to such problems as depression and stress. For stress reduction, ideas and thoughts that are producing stress in the patient are identified, and the therapist then gets the patient to examine the validity of these thoughts. Working together, they restructure thought processes so that the situations seem less stressful. Cognitive therapy has been found to be quite effective in treating depression, as compared with other therapeutic methods. Beck held that depression is caused by certain types of negative thoughts, such as devaluing the self or viewing the future in a consistently pessimistic way.

Rational behavior therapy, developed by psychiatrist Maxie Maultsby, is a close relative of Ellis’s rational emotive therapy. In this approach, Maultsby combines several approaches to include rational emotive therapy, neuropsychology, classical and operant conditioning, and psychosomatic research; however, Maultsby was primarily influenced by his association with Ellis. In this approach, Maultsby attempts to couch his theory of emotional disturbance in terms of neuropsychophysiology and learning theory. Rational behavior therapy assumes that repeated pairings of a perception with evaluative thoughts lead to rational or irrational emotive and behavioral reactions. Maultsby suggests that self-talk, which originates in the left hemisphere of the brain, triggers corresponding right-hemisphere emotional equivalents. Therefore, to maintain a state of psychological health, individuals must practice rational self-talk that will, in turn, cause the right brain to convert left-brain language into appropriate emotional and behavioral reactions.

Rational behavior therapy techniques are quite similar to those of rational emotive therapy. Both therapies stress the importance of monitoring one’s thoughts to become aware of the elements of the emotional disturbance. In addition, Maultsby advocates the use of rational emotive imagery, behavioral practice, and relaxation methods to minimize emotional distress.

Self-Instructional Training

Self-instructional training was developed by psychologist Donald Meichenbaum in the early 1970s. In contrast to Ellis and Beck, whose prior training was in psychoanalysis, Meichenbaum’s roots were in behaviorism and the behavioral therapies. Therefore, Meichenbaum’s approach is heavily couched in behavioral terminology and procedures. Meichenbaum’s work stems from his earlier research in training schizophrenic patients to emit “healthy speech.” By chance, Meichenbaum observed that patients who engaged in spontaneous self-instruction were less distracted and demonstrated superior task performance on a variety of tasks. As a result, Meichenbaum emphasizes the critical role of “self-instructions”—simple instructions such as “Relax . . . Just attend to the task”—and their noticeable effect on subsequent behavior.

Meichenbaum developed self-instructional training to treat the deficits in self-instructions manifested in impulsive children. The ultimate goal of this program was to decrease impulsive behavior. The way to accomplish this goal, as hypothesized by Meichenbaum, was to train impulsive children to generate verbal self-commands and to respond to their verbal self-commands and to encourage the children to self-reinforce their behavior appropriately.

The specific procedures employed in self-instructional training involve having the child observe a model performing a task. While the model is performing the task, he or she is talking aloud. The child then performs the same task while the model gives verbal instructions. Subsequently, the child performs the task while instructing himself or herself aloud, then while whispering the instructions. Finally, the child performs the task while silently thinking the instructions. The self-instructions employed in the program included questions about the nature and demands of the task, answers to these questions in the form of cognitive rehearsal, self-instructions in the form of self-guidance while performing the task, and self-reinforcement. Meichenbaum and his associates have found that this self-instructional training program significantly improves the task performance of impulsive children across a number of measures.

Systematic Rational Restructuring

Systematic rational restructuring is a cognitive behavioral procedure developed by psychologist Marvin Goldfried in the mid-1970s. This procedure is a variation on Ellis’s rational emotive therapy; however, it is more clearly structured than Ellis’s method. In systematic rational restructuring, Goldfried suggests that early social learning experiences teach individuals to label situations in different ways. Further, Goldfried suggests that emotional reactions may be understood as responses to the way individuals label situations, as opposed to responses to the situations themselves. The goal of systematic rational restructuring is to train clients to perceive situational cues more accurately.

The process of systematic rational restructuring is similar to systematic desensitization, in which a subject is to imagine fearful scenes in a graduated order from the least fear-provoking to the most fear-provoking scenes. In systematic rational restructuring, the client is asked to imagine a hierarchy of anxiety-eliciting situations. At each step, the client is instructed to identify irrational thoughts associated with the specific situation, to dispute them, and to reevaluate the situation more rationally. In addition, clients are instructed to practice rational restructuring in specific real-life situations.

Stress Inoculation

Stress inoculation training incorporates several of the specific therapies already described. This procedure was developed by Meichenbaum. Stress inoculation training is analogous to being inoculated against disease. That is, it prepares clients to deal with stress-inducing events by teaching them to use coping skills at low levels of the stressful situation and then gradually to cope with more and more stressful situations. Stress inoculation training involves three phases: conceptualization, skill acquisition and rehearsal, and application and follow-through.

In the conceptualization phase of stress inoculation training, clients are given an adaptive way of viewing and understanding their negative reactions to stressful events. In the skills-acquisition and rehearsal phase, clients learn coping skills appropriate to the type of stress they are experiencing. With interpersonal anxiety, the client might develop skills that would make the feared situation less threatening (for example, learning to initiate and maintain conversations). The client might also learn deep muscle relaxation to lessen tension. In the case of anger, clients learn to view potential provocations as problems that require a solution rather than as threats that require an attack. Clients are also taught to rehearse alternative strategies for solving the problem at hand.

The application and follow-through phase of stress inoculation training involves the clients practicing and applying the coping skills. Initially, clients are exposed to low levels of stressful situations in imagery. They practice applying their coping skills to handle the stressful events, and they overtly role-play dealing with stressful events. Next, clients are given homework assignments that involve gradual exposure to actual stressful events in their everyday life. Stress inoculation training has been effectively applied to many types of problems. It has been used to help people cope with anger, anxiety, fear, pain, and health-related problems (for example, cancer and hypertension). It appears to be suitable for all age levels.

Problem-Solving Therapy

Problem-solving therapy, as developed by psychologists Thomas D’Zurilla and Goldfried, is also considered one of the cognitive behavioral approaches. In essence, problem-solving therapy is the application of problem-solving theory and research to the domain of personal and emotional problems. Indeed, the authors see the ability to solve problems as the necessary and sufficient condition for emotional and behavioral stability. Problem solving is, in one way or another, a part of all psychotherapies.

Cognitive behavior therapists have taught general problem-solving skills to clients with two specific aims: to alleviate the particular personal problems for which clients have sought therapy and to provide clients with a general coping strategy for personal problems.

Clients are given steps of problem solving that they are taught to carry out systematically. First, clients need to define the dilemma as a problem to be solved. Next, they must select a goal that reflects the ultimate outcome they desire. Clients then generate a list of many different possible solutions, without evaluating their potential merit (a kind of brainstorming). They then evaluate the pros and cons of each alternative in terms of the probability that it will meet the goal selected and its practicality, which involves considering the potential consequences of each solution to themselves and to others. They rank the alternative solutions in terms of desirability and practicality and select the highest one. Next, they try to implement the chosen solution. Finally, clients evaluate the therapy, assessing whether the solution alleviated the problem and met the goal, and if not, what went wrong—in other words, which of the steps in problem solving needs to be redone.

Problem-solving therapies have been used to treat a variety of target behaviors with a wide range of clients. Examples include peer relationship difficulties among children and adolescents, examination and interpersonal anxiety among college students, relapse following a program to reduce smoking, harmony among family members, and the ability of chronic psychiatric patients to cope with interpersonal problems.

Self-Control Therapy

Self-control therapy for depression, developed by psychologist Lynn Rehm, is an approach to treating depression that combines the self-regulatory notions of behavior therapy and the cognitive focus of the cognitive behavioral approaches. Essentially, Rehm believes that depressed people show deficits in one or some combination of the following areas: monitoring (selectively attending to negative events), self-evaluation (setting unrealistically high goals), and self-reinforcement (emitting high rates of self-punishment and low rates of self-reward). These three components are further broken down into a total of six functional areas.

According to Rehm, the varied symptom picture in clinically depressed clients is a function of different subsets of these deficits. Over the course of therapy with clients, each of the six self-control deficits is described, with emphasis on how a particular deficit is causally related to depression, and on what can be done to remedy the deficit. A variety of clinical strategies are employed to teach clients self-control skills, including group discussion, overt and covert reinforcement, behavioral assignments, self-monitoring, and modeling.

Structural Psychotherapy

Structural psychotherapy
is a cognitive behavioral approach that derives from the work of two Italian mental health professionals, psychiatrist Vittorio Guidano and psychologist Gianni Liotti. These authors are strongly influenced by cognitive psychology, social learning theory, evolutionary epistemology, psychodynamic theory, and cognitive therapy. Guidano and Liotti suggest that for an understanding of the full complexity of an emotional disorder and subsequent development of an adequate model of psychotherapy, an appreciation of the development and the active role of an individual’s knowledge of self and the world is critical. In short, to understand a patient, one must understand the structure of that person’s world.

Guidano and Liotti’s therapeutic process uses the empirical problem-solving approach of the scientist. Indeed, the authors suggest that therapists should assist clients in disengaging themselves from certain ingrained beliefs and judgments, and in considering them as hypotheses and theories subject to disproof, confirmation, and logical challenge. A variety of behavioral experiments and cognitive techniques are used to assist patients in assessing and critically evaluating their beliefs.

Other Therapies

The area of cognitive behavior therapy involves a wide collection of therapeutic approaches and techniques. Other cognitive behavioral approaches include anxiety management training, which comes from the work of psychologist Richard Suinn, and personal science, from the work of psychologist Michael Mahoney.

The cognitive behavioral approaches are derived from a variety of perspectives, including cognitive theory, classical and operant conditioning approaches, problem-solving theory, and developmental theory. All these approaches share the perspective that internal cognitive processes, called thinking or cognition, affect behavior, and that behavior change may be effected through cognitive change.

These approaches have several other similarities. One is that all the approaches see therapy as time limited. This is in sharp distinction to the traditional psychoanalytic therapies, which are generally open-ended. The cognitive behavior therapies attempt to effect change rapidly, often with specific, preset lengths of therapeutic contact. Another similarity among the cognitive behavior therapies is that their target of change is also limited. For example, in the treatment of depression, the target of change is the symptoms of depression. Therefore, in the cognitive behavioral approaches to treatment, one sees a time-limited focus and a limited target of change.

Evolution

Cognitive behavior therapy evolved from two lines of clinical and research activity: First, it derives from the work of the early cognitive therapists (Ellis and Beck); second, it was strongly influenced by the careful empirical work of the early behaviorists.

Within the domain of behaviorism, cognitive processes were not always seen as a legitimate focus of attention. In behavior therapy, there has always been a strong commitment to an applied science of clinical treatment. In the behavior therapy of the 1950s and 1960s, this emphasis on scientific methods and procedures meant that behavior therapists focused on events that were directly observable and measurable. Within this framework, behavior was seen as a function of external stimuli that determined or were reliably associated with observable responses. Also during this period, there was a deliberate avoidance of such “nebulous” concepts as thoughts, cognitions, or images. It was believed that these processes were by their very nature vague, and one could never be confident that one was reliably observing or measuring these processes.

It is important to note that by following scientific principles, researchers developed major new treatment approaches that in many ways revolutionized clinical practice (among them are systematic desensitization and the use of a token economy). Yet during the 1960s, several developments within behavior therapy had emphasized the limitations of a strict conditioning model to understanding human behavior.

In 1969, psychologist Albert Bandura published his influential volume Principles of Behavior Modification. In this volume, Bandura emphasized the role of internal or cognitive factors in the causation and maintenance of behavior. In response, behavior therapists who were dissatisfied with the radical behavioral approaches to understanding complex human behavior began actively to seek and study the role of cognitive processes in human behavior.

Criticisms and Questions

In the case of depression, cognitive behavior therapy holds that patients’ excessive self-criticism and self-rejection are the causes of their depression. However, other psychologists argue that the patients’ negative thoughts are the result of their depression, and that these patients are better helped through pharmacological means. Other criticisms are that cognitive behavior therapy, because it holds that people’s perceptions of events, rather than events cause their emotions and feelings, does not delve deeply enough when causes of mental illness are deeply rooted in childhood abuse or trauma.

Cognitive behavior therapy has been used in combination with drug therapy in the treatment of schizophrenia and bipolar disorder, with some success. It has been suggested by some psychologists that the best use of cognitive behavior therapy is in combination with other therapies.

Bibliography

Beck, Judith S. Cognitive Behavior Therapy: Basics and Beyond. New York: Guildford, 2011. Print.

Brodsky, Beth B., and Barbara B. Stanley. The Dialectical Behavior Therapy Primer: How DBT Can Inform Clinical Practice. Hoboken: J. J. Wiley, 2013. Print.

D’Zurilla, Thomas J., and Arthur M. Nezu. Problem-Solving Therapy: A Positive Approach to Clinical Intervention. 3d ed. New York: Springer, 2006. Print.

Herbert, James D., and Evan M. Forman. Acceptance and Mindfulness in Cognitive Behavoir Therapy: Understanding and Applying the New Therapies. Hoboken: J. J. Wiley, 2011. Print.

Maultsby, Maxie C., Jr. Rational Behavior Therapy. Englewood Cliffs, N.J.: Prentice-Hall, 1984. Print.

Meichenbaum, Donald. Cognitive Behavior Modification. New York: Plenum, 1979. Print.

Meichenbaum, Donald. Stress Inoculation Training. New York: Pergamon, 1985. Print.

Norcross, John C., and Marvin R. Goldfried, eds. Handbook of Psychotherapy Integration. 2d ed. New York: Oxford University Press, 2005. Print.

O’Donohue, William, and Jane E. Fisher, eds. Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice. 2d ed. Hoboken, N.J.: John Wiley & Sons, 2009. Print.

What is androstenedione as a dietary supplement?

Overview

Androstenedione is a hormone produced naturally in the body by the
adrenal
glands, the ovaries (in women), and the testicles (in men).
The body first manufactures dehydroepiandrosterone (DHEA), then turns DHEA into
androstenedione, and finally transforms androstenedione into testosterone,
the principal male sex hormone. Androstenedione is also transformed into
estrogen.

Androstenedione is widely used by athletes who believe that it can build muscle and increase strength. However, there is no evidence that it works. Furthermore, androstenedione supplements may cause positive urine tests for illegal steroid use because it commonly contains a contaminant (19-norandrostenedione).

Sources

Androstenedione is not an essential nutrient, because the body manufactures it. It is found in meat and in some plants, but to get a therapeutic dosage, supplements are needed.

Therapeutic Dosages

The typical recommended dose of androstenedione is 100 milligrams two times daily with food.

Therapeutic Uses

Androstenedione is said to enhance athletic performance and strength by increasing testosterone production, thereby building muscle. However, in double-blind studies, when androstenedione was given to men, it did not alter total testosterone levels or improve sports performance, strength, or lean body mass. It did, however, increase estrogen levels, an effect that would not be considered favorable. Some evidence suggests that androstenedione does raise testosterone levels in women; again, this is not likely to produce favorable results, and it could cause harm. The most consistent effect of androstenedione is to increase estrogen levels.

Safety Issues

There are concerns that androstenedione, like related hormones, might increase
the risk of liver
cancer and heart disease. In support of this last
consideration, there is some evidence that androstenedione can adversely affect
cholesterol levels. In addition, because androstenedione may raise testosterone
levels in women, it could cause women to develop facial hair and other
male-pattern appearance changes.

According to one case report, the use of androstenedione was associated with loss of libido and decreased sperm count in a twenty-nine-year-old bodybuilder. While a single case report does not prove cause and effect, androstenedione’s apparent ability to raise estrogen levels in men would be consistent with these symptoms.

Another case report suggests an additional potential complication with the use
of androstenedione. A man who was using androstenedione to improve his physique
experienced priapism (painful continuous erection) for more than thirty
hours, requiring emergency care. Previously, also while using androstenedione, he
had experienced an episode lasting two to three hours that spontaneously resolved
itself. It is not certain that androstenedione was the cause, but this appears to
be the most likely possibility.

Bibliography

Ballantyne, C. S., et al. “The Acute Effects of Androstenedione Supplementation in Healthy Young Males.” Canadian Journal of Applied Physiology 25 (2000): 68-78.

Broeder, C. E., et al. “The Andro Project: Physiological and Hormonal Influences of Androstenedione Supplementation in Men 35 to 65 Years Old Participating in a High-Intensity Resistance Training Program.” Archives of Internal Medicine 160 (2000): 3093-3104.

Catlin, D. H., et al. “Trace Contamination of Over-the-Counter Androstenedione and Positive Urine Test Results for a Nandrolone Metabolite.” JAMA 284 (2000): 2618-2621.

Di Luigi, L. “Supplements and the Endocrine System in Athletes.” Clinics in Sports Medicine 27 (2008): 131-151.

Kachhi, P. N., and S. O. Henderson. “Priapism After Androstenedione Intake for Athletic Performance Enhancement.” Annals of Emergency Medicine 35 (2000): 391-393.

Kicman, A. T., et al. “Effect of Androstenedione Ingestion on Plasma Testosterone in Young Women: A Dietary Supplement with Potential Health Risks.” Clinical Chemistry 49 (2003): 167-169.

Leder, B. Z., et al. “Effects of Oral Androstenedione Administration on Serum Testosterone and Estradiol Levels in Postmenopausal Women.” Journal of Clinical Endocrinology and Metabolism 87 (2002): 5449-5454.

Ritter, R. H., A. K. Cryar, and M. R. Hermans. “Oral Androstenedione-Induced Impotence and Severe Oligospermia.” Fertility and Sterility 84 (2005): 217.

How does Prospero tame Caliban in The Tempest?

Prospero teaches Caliban basic skills and then continually threatens him. 

Caliban believes the island is his by right, not Propsero’s. Prospero has magic, though, and can make the inhabitants of the island obey his will. He is particularly cruel with Caliban because he believes Caliban tried to assault his daughter Miranda. Prospero uses Caliban as a slave and punishes him relentlessly. 

When Prospero first landed on the island, he seems to have had a...

Prospero teaches Caliban basic skills and then continually threatens him. 

Caliban believes the island is his by right, not Propsero’s. Prospero has magic, though, and can make the inhabitants of the island obey his will. He is particularly cruel with Caliban because he believes Caliban tried to assault his daughter Miranda. Prospero uses Caliban as a slave and punishes him relentlessly. 

When Prospero first landed on the island, he seems to have had a better relationship with Caliban. Caliban showed him where to find food and fresh water, and Prospero and Miranda taught Caliban their language and other features of their culture, such as the Man in the Moon. Then Caliban targeted Miranda, and that was it. 

PROSPERO

Thou most lying slave,
Whom stripes may move, not kindness! I have used thee,
Filth as thou art, with human care, and lodged thee
In mine own cell, till thou didst seek to violate
The honour of my child. (Act 1, Scene 2) 

Caliban doesn’t deny it, he just says he wishes he was successful because he would have “peopled else/This isle with Calibans.” As a result of this conflict, Prospero calls Caliban his slave, and constantly threatens him with violence.

PROSPERO

If thou neglect'st or dost unwillingly
What I command, I'll rack thee with old cramps,
Fill all thy bones with aches, make thee roar
That beasts shall tremble at thy din.

CALIBAN

No, pray thee.

Aside

I must obey: his art is of such power,
It would control my dam's god, Setebos,
and make a vassal of him. (Act I, Scene 2) 

Caliban knows that, as long as Prospero has magic, there is little he can do. That’s why Caliban tries to convince Trinculo and Stephano to kill Prospero. The three bumble through the rest of the play until Prospero finally forgives Caliban when he gives up his magic and leaves the island.

What is language, and how does it develop?

Introduction

Language is a system of arbitrary symbols that can be combined in conventionalized ways to express ideas, thoughts, and feelings. Language has been typically seen as uniquely human, separating the human species from other animals. Language enables people of all cultures to survive as a group and preserve their culture. The fundamental features of human language make it extremely effective and very economical. Language uses its arbitrary symbols to refer to physical things or nonphysical ideas; to a single item or a whole category; to a fixed state or to a changing process; to existent reality or to nonexistent fiction; to truths or to lies.

Language is systematic and rule-governed. Its four component subsystems are phonology, semantics, grammar, and pragmatics. The phonological system uses phonemes (the smallest speech sound units capable of differentiating meanings) as its building blocks to form syllables and words through phonemic rules. For example, /m/ and /n/ are two different phonemes because they differentiate meaning as in /mĪt/ (meat) versus /nĪt/ (neat), and “meat” has three phonemes of /m/, /Ī/, and /t/ placed in a “lawful” order in English to form one syllable. The semantic system makes language meaningful. It has two levels: Lexical semantics refers to the word meaning, and grammatical semantics to the meaning derived from the combinations of morphemes (the smallest meaning units) into words and sentences. “Beds,” for example, has two morphemes, “bed” as a free morpheme means “a piece of furniture for reclining or sleeping,” and “s” as a bound morpheme means “more than one.”

The grammatical system includes morphology and syntax. Morphology specifies rules to form words (for example, prefixes, suffixes, grammatical morphemes such as “-ed,” and rules to form compound words such as “blackboard”). Syntax deals with rules for word order in sentences (such as, “I speak English,” but not “I English speak”). Furthermore, the syntax of human language has four core elements, summarized in 1999 by Edward Kako as discrete combinatorics (each word retains its general meaning even when combined with other words), category-based rules (phrases are built around word categories), argument structure (the arguments or the participants involved in an event, labeled by verbs, are assigned to syntactic positions in a sentence), and closed-class vocabulary (the grammatical functional words, such as “the,” “on,” or “and,” are usually not open to addition of new words).

The fourth subsystem in human language is the pragmatic system. It involves rules to guide culture-based, appropriate use of language in communication. For example, people choose different styles (speech registers) that they deem appropriate when they talk to their spouses versus their children. Other examples include the use of contextual information, inferring the speaker’s illocutionary intent (intended meaning), polite expressions, conversational rules, and referential communication skills (to speak clearly and to ask clarification questions if the message is not clear).

Language is creative, generative, and productive. With a limited number of symbols and rules, any language user is able to produce and understand an unlimited number of novel utterances. Language has the characteristic of displacement; that is, it is able to refer to or describe not only items and events here and now but also items and events in other times and places.

Language Acquisition and Development

Views on language acquisition and developmentare diverse. Some tend to believe that language development follows one universal path, shows qualitatively different, stage-like shifts, proceeds as an independent language faculty, and is propelled by innate factors. Others tend to believe in options for different paths, continuous changes through learning, and cognitive prerequisites for language development.

A Universal Pathway in Language Development

Stage theories usually suggest a universal path (an invariant sequence of stages) for language development. A typical child anywhere in the world starts with cooing (playing with the vowel sounds) at two to three months of age, changes into babbling (consonant-vowel combinations) at four to six months, begins to use gestures at nine to ten months, and produces first words by the first birthday. First word combinations, known as telegraphic speech (content word combinations with functional elements left out, such as “Mommy cookie!”), normally appear when children are between 1.5 and 2.5 years. Meanwhile, rapid addition of new words results in a vocabulary spurt. Grammatical rules are being figured out, as seen in young children’s application of regular grammatical rules to irregular exceptions (called over-regularization, as in “I hurted my finger”). Later on, formal education promotes further vocabulary growth, sentence complexity, and subtle usages. Language ability continues to improve in early adulthood, then remains stable, and generally will not decline until a person reaches the late sixties.

Different Pathways in Language Development

Although the universal pattern appears true in some respects, not all children acquire language in the same way. Analyses of young children’s early words have led psychologists to an appreciation of children’s different approaches to language. In her 1995 book Individual Differences in Language Development, Cecilia Shore analyzed the different pathways of two general styles (sometimes termed analytic versus holistic)
in the four major language component areas.

In early phonological development, holistic babies seem to attend to prosody or intonation. They tend to be willing to take risks to try a variety of sound chunks, thus producing larger speech units in sentence-like intonation but with blurred sounds. Analytic babies are phonemic-oriented, paying attention to distinct speech sounds. Their articulation is clearer.

In semantic development, children differ not only in their vocabulary size but also in the type of words they acquire. According to Katherine Nelson (cited in Shore’s work), who divided children’s language acquisition styles into referential versus expressive types, the majority of the referential babies’ first words were object labels (“ball,” “cat”) whereas many in the expressive children’s vocabulary were personal-social frozen phrases (“Don’t do dat”). In Shore’s opinion, the referential babies are attracted to the referential function of nouns and take in the semantic concept of object names; the expressive children attend more to the personal-social aspect of language and acquire relational words, pronouns, and undifferentiated communicative formulaic utterances.

Early grammatical development shows similar patterns. The analytical children are more likely to adopt the nominal approach and use telegraphic grammar to combine content words but ignore the grammatical inflections (such as the plural “-s”). The holistic children have a tendency to take the pronominal approach and use pivot-open grammar to have a small number of words fill in the frame slots (for instance, the structure of “allgone [ . . . ]” generates “allgone shoe,” “allgone cookie,” and so on). The units of language acquisition might be different for different children.

In the area of pragmatic development, children may differ in their understanding of the primary function of language. Nelson has argued that the referential children may appreciate the informative function of language and the expressive children may attend to the interpersonal function of language. The former are generally more object-oriented, are declarative, and display low variety in speech acts, whereas the latter are more person-oriented, are imperative, and display high variety in speech acts.

Convenient as it is to discuss individual differences in terms of the two general language acquisition styles (analytic versus holistic), it does not mean that the two are necessarily mutually exclusive—children actually use both strategies, although they might use them to different extents at different times and change reliance patterns over time.

Theories of Language Development

With an emphasis on language performance (actual language use in different situations) rather than language competence (knowledge of language rules and structure), learning theories contend that children learn their verbal behavior (a term suggested by the behaviorist B. F. Skinner in 1957 to replace the vague word of “language”) primarily through conditioning and imitation, not maturation. Classical conditioning
allows the child to make associations between verbal stimuli, internal responses, and situational contexts to understand a word’s meaning. It also enables the child to comprehend a word’s connotative meaning—whether it is associated with pleasant or unpleasant feelings. Operant conditioning shapes the child’s speech through selective reinforcement and punishment. Adults’ verbal behaviors serve as the environmental stimuli to elicit the child’s verbal responses, as models for the child to imitate, and as the shaping agent (through imitating their children’s well-formed speech and recasting or expanding their ill-formed speech).

Nevertheless, learning theories have difficulty explaining many phenomena in language development. Imitation cannot account for children’s creative yet logical sayings, such as calling a gardener “plantman,” because there are no such models in adult language. Shaping also falls short of an adequate explanation, because adults do not always correct their children’s mistakes, especially grammatical ones. Sometimes they even mimic their children’s cute mistakes. Furthermore, residential homes are not highly controlled laboratories—the stimulus-response-consequence contingencies are far from perfect.

The Nativist Perspective

The nativist perspective, turning to innate mechanisms for language development, has the following underlying assumptions: language is a human-species-specific capacity; language is “unlearnable” because it is impossible for a naïve and immature child to figure out such a complex linguistic system from an imperfect, not very consistent, highly opaque, and frequently ambiguous language environment; and there is a common structural core in all human languages. In 1965, linguist Noam Chomsky posited an innate language-acquisition device (LAD), with the universal grammar residing in it, to explain children’s rapid acquisition of any language and even multiple languages. LAD is assumed to be a part of the brain, specialized for processing language. Universal grammar is the innate knowledge of the grammatical system of principles and rules expressing the essence of all human languages. Its transformational generative grammar consists of rules to convert the deep structure (grammatical classes and their relationships) to surface structure (the actual sentences said) in the case of production, or vice versa in the case of comprehension. Equipped with this biological endowment, children need only minimal language exposure to trigger the LAD, and their innate knowledge of the universal grammar will enable them to extract the rules for the specific language(s) to which they are exposed.

Evidence for the nativist perspective can be discussed at two levels: the linguistic level (language rules and structure) and the biological level. At the linguistic level, people are sensitive to grammatical rules and linguistic structural elements. For example, sentences in the active voice are processed more quickly than sentences in the passive voice, because the former type is closer to the deep structure and needs fewer transformation steps than the latter type. Click insertion studies (which insert a click at different places in a sentence) and interrupted tape studies (which interrupt a tape with recorded messages at different points) have shown a consistent bias for people to recall the click or interruption position as being at linguistic constituent boundaries, such as the end of a clause. After a sentence has been processed, what remains in memory is the meaning or the gist of the sentence, not its word-for-word surface structure, suggesting the transformation from the surface structure to the deep structure.

Around the world, the structure of creolized languages (invented languages), including the sign languages invented by deaf children who have not been exposed to any language, is similar and resembles early child language. Young children’s early language data have also rendered support. In phonology, habituation studies show that newborns can distinguish between phonemes such as /p/ and /b/. Most amazingly, they perceive variations of a sound as the same if they come from the same phoneme, but different if they cross the boundary into a different phoneme (categorical speech perception). In semantics, babies seem to know that object labels refer to whole objects and that a new word must mean the name of a new object. If the new word is related to an old object whose name the child already knows, the word must mean either a part or a property of that object (the mutual exclusivity hypothesis). In the domain of grammar, Dan Isaac Slobin’s 1985 cross-cultural data have shown that young children pay particular attention to the ends of words and use subject-object word order, probably as a function of their innate operating principles. By semantic bootstrapping, young children know that object names are nouns and that action words are verbs. By syntactic bootstrapping, they understand a word’s grammatical class membership according to its position in a sentence. Even young children’s mistaken over-regularization of grammatical rules to exceptions demonstrates their success in rule extraction, since such mistaken behavior is not modeled by adults.

The Neural Storehouse

At the biological level, human babies seem to be prepared for language: They prefer the human voice to other sounds and the human face to other figures. Some aspects of the language developmental sequence appear to be universal—even deaf children, despite their lack of language input, start to coo and babble at about the same ages as hearing children and later develop sign combinations that are very similar to telegraphic speech. Children’s language environment is indeed quite chaotic, yet it takes them only four to five years to speak their mother tongue like an adult without systematic, overt teaching. Furthermore, a critical or sensitive period seems to exist for language acquisition. Young children are able to pick up any language or a second language effortlessly, with no accent or grammatical mistakes. After puberty, people generally have to exert great efforts to learn another language, and their pronunciation as well as grammar typically suffers. Reinforced language teaching in postcritical years was not successful in the cases of “Victor” (a boy who had been deserted in the wild) and “Genie” (a girl who had been confined in a basement). Kako’s 1999 study—a careful analysis of the linguistic behavior of a parrot, two dolphins, and a bonobo—led him to conclude that no nonhuman animals, including the language-trained ones, show all the properties of human language in their communication, although he respectfully acknowledges all the achievements in animal language training. Language is unique to human beings.

Although the neural storehouse for the universal grammar has not been pinpointed yet, cognitive neuroscience has delivered some supportive evidence. Infants’ brains respond asymmetrically to language sounds versus nonlanguage sounds. Event-related potentials (ERPs) have indicated localized brain regions for different word categories in native English speakers. Research suggests possible specific brain structures that had registered a detailed index for nouns. Brain studies have confirmed the left hemisphere’s language specialization relative to the right hemisphere, even among very young infants. Broca’s area and Wernicke’s area are housed in the left hemisphere. Damage to Broca’s area results in Broca’s aphasia, with a consequence of producing grammatically defective, halting, telegram-like speech. When Wernicke’s area is damaged, speech fluency and grammatical structure are spared but semantics is impaired. This linguistic lateralization pattern and the linguistic consequences of brain injuries are also true of normal and aphasic American Sign Language users.

However, the nativist perspective is not immune to criticism. The universal grammar cannot adequately explain the grammatical diversity in all human languages. The growth spurts in brain development do not correspond to language development in a synchronized manner. The importance of social interaction, contextual factors, and formal education for knowledge and pragmatic usage of complex rules, subtle expressions, speech acts, and styles has been neglected in nativist theories.

Dissatisfied with this nature-nurture dichotomy, interactionist theories try to bring the two together. They recognize the reciprocal influences, facilitating or constraining, dependent or modifying, among multiple factors from the biological, cognitive, linguistic, and social domains. For instance, the typical prenatal and postnatal mother-tongue environment will eventually wean the infants’ initial ability to differentiate the speech sounds of any language and, at the same time, sharpen their sensitivity to their native language. Deaf children’s babbling does not develop into words as does that of hearing children. Babies deprived of the opportunity of social interaction, as seen in the cases of “Victor” and “Genie,” will not automatically develop a proper language. It is in the dynamic child-environment system that a child acquires language.

Language and Cognition

Cognitive Development and Language Acquisition

Cognitive theorists generally believe that language is contingent on cognitive development. The referential power in the arbitrary symbols assumes the cognitive prerequisite of understanding the concepts they signify. As a cognitive interactionist, Jean Piaget believed that action-based interaction with the world gave rise to the formation of object concepts, separation of self from the external world, and mental representation of reality by mental images, signs, and symbols (language). Language reflects the degree of cognitive maturity. For example, young children’s immature egocentric thought (unable to understand others’ perspectives) is revealed in their egocentric speech (talking to self)—children seem to show no realization of the need to connect with others’ comments or to ascertain whether one is being understood. Older children’s cognitive achievements of logical thinking and perspective-taking lead to the disappearance of egocentric speech and their use of socialized speech for genuine social interaction. Although language as a verbal tool facilitates children’s interaction with the world, it is the interaction that contributes to cognitive development. Piaget gave credit to language only in the later development of abstract reasoning by adolescents.

In L. S. Vygotsky’s social-functional interactionist view, language and cognition develop independently at first, as a result of their different origins in the course of evolution. Infants use practical/instrumental intelligence (intelligence without speech), such as smiling, gazing, grasping, or reaching, to act on or respond to the social world. Meanwhile, the infants’ cries and vocalizations, though they do not initially have true communicative intent (speech without thinking), function well in bringing about adults’ responses. Adults attribute meaning to infants’ vocalizations and thus include the babies in the active communicative system, fostering joint attention and intersubjectivity (understanding each other’s intention). Such social interactions help the infants eventually complete the transition from nonintentional to intentional behavior and to discover the referential power of symbols, thus moving on to verbal thinking and later to meaningful speech. Externalized speech (egocentric speech) is a means for the child to monitor and guide his or her own thoughts and problem-solving actions. This externalized functional “conversation with oneself” (egocentric speech) does not disappear but is internalized over time and becomes inner speech, a tool for private thinking. Thus, in Vygotsky’s theory, language first develops independently of cognition, then intersects with cognition, and contributes significantly to cognitive development thereafter. Language development proceeds from a global, social functional use (externalized speech) to a mature, internalized mastery (inner speech), opposite to what Piaget suggested.

Linguistic Relativity

Linguistic relativity refers to the notion that the symbolic structure and use of a language will shape its users’ way of thinking. The Sapir-Whorf hypothesis, also known as linguistic determinism, is a strong version. According to anthropologist John Lucy, writing in 1997, all the variations of linguistic relativity, weak or strong, share the assumption that “certain properties of a given language have consequences for patterns of thought about reality. . . . Language embodies an interpretation of reality and language can influence thought about that reality.” Many researchers have tested these claims. Lera Boroditsky, for example, in a 2001 study, examined the relationship between spatial terms used to talk about time and the way Mandarin Chinese speakers (using vertical spatial metaphors) and English speakers (using horizontal spatial metaphors) think about time. The findings suggested that abstract conceptions, such as time, might indeed be subject to the influence from specific languages. On the other hand, the influence between language and thought might be more likely bidirectional than unidirectional. Many examples from the civil rights movement or the feminist movement, such as the thought of equality and bias-free linguistic expressions, can be cited to illustrate the reciprocal relationships between the two.

Language Faculty as a Module

There have been debates over whether language is a separate faculty or a part of general cognition. Traditional learning theories are firm in the belief that language is a learned verbal behavior shaped by the environment. In other words, language is not unique in its own right. By contrast, nativist theorists insist on language being an independent, innate faculty. Chomsky even advocates that, being one of the clearest and most important separate modules in the individual brain, language should be viewed internally from the individual and therefore be called internal language or “I-language,” distinct from “E-language” or the external and social use of language. Nativists also insist on language being unique to humans, because even higher-order apes, though they have intelligence (such as tool using, problem solving, insights) and live a social life, do not possess a true language.

The view of language as an independent faculty has received support from works in cognitive neuroscience, speech-processing studies, data associated with aphasia (language impairment due to brain damage), and unique case studies. Specific word and grammatical categories seem to be registered in localized regions of the brain. Some empirical studies have suggested that lexical access and word-meaning activation appear to be autonomic (modular). As noted, Broca’s aphasia and Wernicke’s aphasia display different language deficit symptoms. In 1991, Jeni Yamada reported the case of Laura, a person with an IQ score of just 41 when she was in her twenties. Her level of cognitive problem-solving skill was comparable to that of a preschooler, yet she was able to produce a variety of grammatically sophisticated sentences, such as “He was saying that I lost my battery-powered watch that I loved; I just loved that watch.” Interestingly, Laura’s normal development in phonology, vocabulary, and grammar did not protect her from impairment in pragmatics. In responding to the question, “How do you earn your money?,” Laura answered, “Well, we were taking a walk, my mom, and there was this giant, like, my mother threw a stick.” It seems that some components of language, such as vocabulary and grammar, may function in a somewhat autonomic manner, whereas other parts, such as pragmatics, require some general cognitive capabilities and social learning experiences.

Cognitive psychologists hold that language is not a separate module but a facet of general cognition. They caution people against hasty acceptance of brain localization as evidence for a language faculty. Arshavir Blackwell and Elizabeth Bates (1995) have suggested an alternative explanation for the agrammaticality in Broca’s aphasia: grammatical deficits might be the result of a global cognitive resource diminution, rather than just the damaged Broca’s area. In 1994, Michael Maratsos and Laura Matheny criticized the inadequate explanatory power of the language-as-a-faculty theory pertaining to the following phenomena: comprehension difficulties in Broca’s aphasia in addition to grammatical impairment; semantically related word substitutions in Wernicke’s aphasia; the brain’s plasticity or elasticity (the flexibility of other parts of the brain adapting to pick up some of the functions of the damaged parts); and the practical inseparability of phonology, semantics, syntax, and pragmatics from one another.

Some information-processing models, such as connectionist models, have provided another way to discuss language, not in the traditional terms of symbols, rules, or cognitive capacity, but in terms of the strengths of the connections in the neural network. Using computer modeling, J. L. McClelland explains that knowledge is stored in the weights of the parameter connections, which connect the hidden layers of units to the input units that process task-related information and the output units that generate responses (performance). Just like neurons at work, parallel-distributed processing, or many simultaneous operations by the computer processor, will result in self-regulated strength adjustments of the connections. Over extensive trials, the “learner” will go through an initial error period (the self-adjusting, learning period), but the incremental, continual change in the connection weights will give rise to stage-like progressions. Eventually, the machine gives rule-like performance, even if the initial input was random, without the rules having ever been programmed into the system. These artificial neural networks have successfully demonstrated developmental changes or stages in language acquisition (similar to children’s), such as learning the past tense of English verbs.

As a product of the neural network’s experience-driven adjustment of its connection weights, language does not need cognitive prerequisites or a specific language faculty in the architecture (the brain). Although emphasizing learning, these models are not to prove the tabula rasa (blank slate) assumption of traditional behaviorism, either, because even small variations in the initial artificial brain structure can make qualitative differences in language acquisition. The interaction between the neural structure and environment (input cues and feedback patterns) is further elaborated in dynamic systems models. For example, Paul van Geert’s dynamic system, proposed in 1991, is an ecosystem with heuristic principles modeled after the biological system in general and the evolutionary system in particular. The system space consists of multiple growers or “species” (such as vocabulary and grammatical rules) in interrelated connections. Developmental outcome depends on the changes of the components in their mutual dependency as well as competition for the limited internal and external resources available to them.

Conclusion

As Thomas M. Holtgraves said in 2002, “It is hard to think of a topic that has been of interest to more academic disciplines than language.” Language can be analyzed at its pure, abstract, and symbolic structural level, but it should also be studied at biological, psychological, and social levels in interconnected dynamic systems. Continued endeavors in interdisciplinary investigations using multiple approaches will surely lead to further understanding of language.

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What is elder abuse? |

Introduction

Elder abuse is the physical, emotional, or psychological injury or risk of injury; financial exploitation; or neglect in providing basic needs of an older adult. Although there is no universally accepted definition of old age, generally sixty or sixty-five years is considered the beginning of old age. Older Americans are the fastest growing population in the United States. According to the US Census Bureau, individuals sixty-five years of age and older made up more than 13 percent of the US population in 2012; that number is expected to increase to more than 20 percent by 2050, according to estimates by the US Department of Health and Human Services' Administration on Aging. As more responsibility is placed on family members to care for aging relatives, elder abuse is likely to increase as well.

Elder abuse usually constitutes repetitive acts of commission or omission that threaten the health and welfare of an older adult. Elder abuse does not receive the same recognition as child abuse and spousal violence and is often underreported or not reported at all. As such, the number of abused elders is probably highly underestimated. Victims often do not report abuse because they are embarrassed, fearful of repercussions by their caregivers, and likely to harbor feelings of guilt if they report their only source of shelter, support, and care.

Because so few people report elder abuse, it is important for health care providers to identify and know their obligations to report such abuse. In 1981, Congress proposed legislation to establish a national center on elder abuse, but the bill never reached the floor of Congress. In 1989, it was reintroduced as an amendment to the Older Americans Act, and elder abuse was finally recognized in federal legislation.

Types of Abuse

Physical abuse is the deliberate infliction of physical pain or injury. Examples include slapping, punching, bruising, or restraining. Psychological abuse is the infliction of mental or emotional anguish. Examples include verbal insults, humiliation, or threats. Financial exploitation is using the resources of an elderly person without consent. Examples include writing checks without permission and stealing money. Neglect is failure of a caretaker to provide basic needs to prevent physical harm, mental anguish, or illness. Examples include withholding nourishment, ignoring cleanliness, and neglecting physical needs. Self-neglect occurs when an elderly person compromises his or her health and safety by refusing assistance in care. Examples include refusing to eat and refusing needed medications. Sexual abuse is any unwanted sexual behavior. Examples include inappropriate touching and rape.

Possible Causes

Risks for elder abuse are divided into four major categories: physical and mental impairment of the victim, caregiver stress, transgenerational violence, and abuser psychopathology. Impairment of a dependent elder and a family history of violence and substance abuse are also identified as causes for elder abuse.

Though studies do not relate the victim’s level of frailty to abuse, physical and mental impairment indirectly increase the risk of abuse because the victims are unable to leave an abusive environment or effectively defend themselves.

Caregiver stress may result in acting out anger toward the elderly person. Stress factors contributing to such outbursts may be related to the victim as well as to the caregiver and include alcohol or drug abuse, employment issues, low income, increased risk of falls, incontinence, verbal or physical aggression, and poor caregiving skills caused by a lack of knowledge about how to care for the elderly.

Transgenerational violence supports the premise that abuse is a learned behavior passed between generations. As such, a child who was abused by a parent may be abusive to the parent on becoming the caregiver. Domestic violence can persist throughout the life span and does not necessarily stop in old age.

Abuser psychopathology relates elder abuse to substance abuse and addiction, personality and mental disorders, and dementia. Risk factors for elder abuse as identified by the American Medical Association include living with the abuser, dementia, social isolation, and mental illness as well as alcohol or drug use by the caregiver. Other theories that have been used to explain elder abuse are exchange theory, which proposes dependencies between a victim and a perpetrator related to reactions and responses that continue into adulthood;
social learning theory, which proposes that abuse is learned; and political economic theory, which proposes that the challenges faced by elders leave them in poverty and take away their importance in community life. Political economic theory addresses the marginalization of elders in society.

Prevention

Every state in the United States defines elder abuse, has passed elder abuse prevention laws, and employs some form of an elder abuse reporting system. Unfortunately, laws and the definition of abuse are inconsistent among states. Adult Protective Services (APS) are available in every state but provide assistance only when the victim agrees or is rendered mentally incapable to make decisions by the courts. Education about what constitutes abuse and neglect needs to be clear. Additionally, an understanding that abusive behavior in any form is never acceptable needs to be established. Finally, information about counseling for caregivers should be available so they know that services and support exist for them when they require it. Educating the public and raising public awareness of the extent of elder abuse are effective ways to prevent elder abuse. Increased social services to provide support for caregivers, respite care and counseling for family, and information about social issues that are triggers for abuse can be instrumental in preventing abuse. Developing an understanding of the risk factors for elder abuse and its signs and symptoms are also crucial in preventing cases of elder abuse.

Psychology Today offers some tips for older adults to keep them safe from abuse. These tips include maintaining a social life, remaining in touch with friends after moving in with a relative, asking a friend to check in weekly, and inviting friends to visit often. Older adults are also encouraged to make new friends and participate in community activities. They should check their own mail, report instances in which mail is intercepted, and have their own telephones. They should keep track of their belongings and make others aware that they know where everything should be. Older adults should attend to their personal needs as much as possible and keep appointments with doctors and dentists and other planned activities. They should maintain financial control and have Social Security or pension checks deposited directly to a personal bank account. Older adults should obtain legal advice about possible future disability, wills, property, powers of attorney, guardianships, or conservatorships. They should keep records, accounts, and property available for trusted people to manage affairs when they no longer can. They should not live with a person who exhibits violent behavior or alcohol or drug abuse. They should not leave their homes unattended for lengths of time or leave signs that they are not home, such as notes on the door. Instead, they should notify the police when they will be away. Older adults should not leave cash, jewelry, or other valuables in nonsecure locations. They should not accept personal care in return for the transfer or assignments of property unless a lawyer, advocate, or trusted person acts as a witness. They should not sign documents unless someone they trust has reviewed it and should not allow anyone to keep details of their finances or property management from them.

Diagnosis and Screening

Elder abuse often goes undetected because its signs and symptoms may be missed or victims may deny that injuries are a result of abuse. Symptoms may be mistaken for dementia, or caregivers may explain them to others in that way. Because elder abuse can present itself in many different ways, injuries must be evaluated based on the victim’s general health and psychosocial environment. If elder abuse is diagnosed, then the victim’s safety must be ensured while respecting his or her autonomy and independence. Some alerts for suspected abuse include bruises and lacerations; broken or fractured bones, untreated injuries in various stages of healing; sprains, dislocations, and internal injuries; medication overdoses or underutilization of prescribed drugs; a victim’s report of being hit, kicked, or mistreated; a sudden change in behavior, such as agitation, depression, or withdrawal; dehydration or malnutrition; untreated bedsores and poor hygiene; untreated health problems; unsafe or unclean living conditions; and a caregiver’s refusal of visitors.

Besides the physical signs of abuse, there are a variety of assessment tools for screening for elder abuse. Health care providers should screen patients who are sixty years of age and older for abuse at least annually. Some questions that the American Medical Association suggests should be asked are the following:
Has anyone at home ever hurt you?


Has anyone ever touched you without your consent?


Has anyone taken anything that was yours without asking?


Has anyone ever threatened you?


Have you ever signed any documents that you didn’t understand or you didn’t want to sign?


Are you afraid of anyone at home?


Are you alone a lot?


Has anyone ever failed to help you take care of yourself when you needed help?

Reporting Abuse

Area Agency on Aging, the county Department of Social Services, and Adult Protective Services are agencies that investigate elder abuse and neglect. State ombudsman’s offices are instrumental in investigating and identifying elder abuse in long-term-care facilities. Once abuse or neglect is confirmed, protection services are mobilized. If the victim is mentally competent, then the victim must agree to accept the assistance. Alternately, the victim must be deemed by the courts to be mentally incapable of making decisions before assistance is mobilized.

All people share responsibility for reporting suspected cases of elder abuse. Professionals such as social workers, police officers, teachers, physicians, nurses, and those who provide services to the elderly are required by law to report suspected cases of elder abuse. One resource for reporting is the Eldercare Locator Hotline at (800) 677-1116. Calls are directed to a local agency for assistance. If 911 is called for suspected elder abuse, then the local police will intervene.

Bibliography

“Elder abuse.” HelpGuide.org. http://www.helpguide.org/mental/.

“Elder or dependent abuse.” Psychology Today. http://www.psychologytoday.com/conditions/.

Hall, Barbara, and Terry Scragg, eds. Social Work with Older People: Approaches to Person-Centered Practice. New York: McGraw-Hill, 2012. Print.

Heath, J. M., F. A. Kobylarz, and M. Brown. “Interventions from Home-Based Geriatric Assessments of Adult Protective Service Clients Suffering Elder Mistreatment.” Journal of American Geriatric Society 53 (2005): 1538–42. Print.

Koenig, R. J., and C. R. DeGuerre. “The Legal and Governmental Response to Domestic Elder Abuse.” Clinical Geriatric Medicine 21.2 (2005): 383–98. Print.

Murray, Christine E., and Kelly N. Graves. Responding to Family Violence: A Comprehensive, Research-Based Guide for Therapists. New York: Routledge, 2013. Print.

Phelan, Amanda, ed. International Perspectives on Elder Abuse. New York: Routledge, 2013. Print.

"Projected Future Growth of the Older Population." Administration on Aging. Dept. of Health and Human Services, n.d. Web. 15 May 2014.

Quinn, K., and H. Zielke. “Elder Abuse, and Exploitation: Policy Issues.” Clinical Geriatric Medicine 21.2 (2005): 449–57. Print.

Sellas, Monique, and Laurel Krouse. “Elder Abuse Overview.” http://emedicine.medscape.com/article/.

"USA." United States Census Bureau. US Dept. of Commerce, 27 Mar. 2014. Web. 15 May 2014.

How does genetic engineering affect the environment?

There are at least two ways we can approach this question: by asking how the GMOs themselves affect the environment, and evaluating how their use affects human practices that impact the environment.

One of the most common targets for criticism and application of GMOs is the agriculture industry. Companies are successfully engineering new types of crops, sold in seed form, that offer a variety of benefits, such as resistance to pesticides or higher crop yields....

There are at least two ways we can approach this question: by asking how the GMOs themselves affect the environment, and evaluating how their use affects human practices that impact the environment.

One of the most common targets for criticism and application of GMOs is the agriculture industry. Companies are successfully engineering new types of crops, sold in seed form, that offer a variety of benefits, such as resistance to pesticides or higher crop yields. One of the downsides of this, from the consumer perspective, is that farmers are sometimes not allowed to keep seeds from one year's harvest to plant in the next; the seeds and their genetic content are technically the property of the company that creates them. Further, it's entirely possible the seeds and crops could be intentionally or accidentally transported beyond the areas they are intended to be planted in, displacing native species due to superior traits. This would be another form of human-caused invasive species potentially leading to an ecological collapse.

On the other hand, the use of modified organisms may have positive effects on the environment due to factors such as the aforementioned built-in resistances, or they could be modified to require less water, less nutrients in the soil, or resistance to infection. All of these factors would reduce the ecological impacts demanded in order to care for them. Increased crop yields would also reduce the amount of land necessary to grow food, or increase the yield of the land used, which is a necessary consideration in light of the expanding world population and the limited space available for agriculture.