© 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.
1. SCOPE OF PRACTICE 1A. MFT SCOPE OF PRACTICE 1B. LCSW SCOPE OF PRACTICE 2. UNPROFFESIONAL CONDUCT, NEGLIGENCE, LAW, ETHICS, AND STANDARD OF CARE 2A. UNPROFESSIONAL CONDUCT AND NEGLIGENCE 2B. LAW 2C. ETHICS 2D. STANDARD OF CARE 3. LEGAL ISSUES 3A. PRIVILEGE 3B. CONFIDENTIALITY 3C. EXCEPTIONS TO CONFIDENTIALITY: CHILD ABUSE, DEPENDENT ADULT & ELDER ABUSE , TARASOFF, DANGER TO SELF 3D. TREATMENT OF MINORS 3E. SEX WITH CLIENTS 3F. RECORD RETENTION AND STORAGE 3G. TERMINATION 3H. INFORMED CONSENT 3I. MALPRACTICE 4. HIPAA AND THIRD PARTY REIMBURSEMENT FOR MENTAL HEALTH SERVICES 5. CONTINUING EDUCATION 6. PROFESSIONAL ETHICS 6A. CAMFT ETHICAL STANDARDS PT II SECTION D 6B. REVISED CAMFT ETHICAL STANDARDS 6C. NASW ETHICAL STANDARDS 7. REFERENCES
1. Scope of Practice
The Attorney General describes scope of practice as the following: 1. MFTs and LCSWs “may practice psychotherapy” as it relates to the treatment of relational issues and social adjustments. 2. MFTs and LCSWs may diagnose and treat mental disorders as it relates to the treatment of relational issues and social adjustments. 3. MFTs and LCSWs may administer psychological tests, as long as the testing instrument used is within a therapist’s scope of competence as established by education, training, or experience and as long as the test is administered within the context of providing therapy. In other words, stand-alone testing of persons who are not psychotherapy clients would be outside the scope of practice for MFTs and LCSWs. Circumstances exist in which a “special relationship” is presumed by law to exist when one person is particularly vulnerable and dependent on another person who, correspondingly, has some control over the person’s welfare (Kockelman v. Segal, 1998). The relationship between a therapist and his or her patient constitutes this type of relationship. This special relationship imposes an affirmative duty on the therapist to protect others from either the therapist’s own negligence or from the client’s dangerousness towards self or others. 1A. MFT Scope of Practice MFT scope of practice is defined in Section 4980.02 of the California Business and Professions Code, “For the purposes of this chapter, the practice of marriage, family, and child counseling shall mean that service performed with individuals, couples, or groups wherein interpersonal relationships are examined for the purpose of achieving more adequate, satisfying, and productive marriage and family adjustments. This practice includes relationship and pre-marriage counseling. The applications of marriage, family, and child counseling principles and methods includes, but is not limited to, the use of applied psychotherapeutic techniques, to enable individuals to mature and grow within marriage and the family, and the provision of explanations and interpretations of the psychosexual and psychosocial aspects of relationships.” Pursuant to Business and Professions Code Section 4980.08, effective July 1, 1999, the title "licensed marriage, family and child counselor" or "marriage, family and child counselor" is hereby renamed "licensed marriage and family therapist" or "marriage and family therapist," respectively. Any reference in any statute or regulation to a "licensed marriage, family and child counselor" or "marriage, family and child counselor" shall be deemed a reference to a "licensed marriage and family therapist" or "marriage and family therapist."
1B. LCSW Scope of Practice LCSW scope of practice is defined in Section: 4996.9 of the California Business and Professions Code, “The practice of clinical social work is defined as a service in which a special knowledge of social resources, human capabilities, and the part that unconscious motivation plays in determining behavior, is directed at helping people to achieve more adequate, satisfying, and productive social adjustments. The application of social work principles and methods includes, but is not restricted to, counseling and using applied psychotherapy of a non-medical nature with individuals, families, or groups; providing information and referral services; providing or arranging for the provision of social services; explaining or interpreting the psychosocial aspects in the situations of individuals, families, or groups; helping communities to organize, to provide, or to improve social or health services; or doing research related to social work. “Psychotherapy, within the meaning of this chapter, is the use of psychosocial methods within a professional relationship, to assist the person or persons to achieve a better psychosocial adaptation, to acquire greater human realization of psychosocial potential and adaptation, to modify internal and external conditions which affect individuals, groups, or communities in respect to behavior, emotions, and thinking, in respect to their intrapersonal and interpersonal processes.”
2. UNPROFFESIONAL CONDUCT, NEGLIGENCE, LAW, ETHICS, AND STANDARD OF CARE
2A. Unprofessional Conduct and Negligence
The Business and Professions Code, Section 4982 indicates examples of unprofessional conduct including “negligence or incompetence in the performance of marriage and family therapy; misrepresentation involving type of license held, educational credentials, professional qualification or professional affiliations; performing, or holding oneself out as being able to perform services outside the scope of the license; failing to maintain confidentiality, except as otherwise permitted or required by law; and soliciting or paying remuneration for referrals. Unprofessional conduct is punishable by revocation or suspension of a license or an intern's registration; it is also a misdemeanor punishable by imprisonment in the county jail not exceeding six months, by a fine not exceeding $2,500, or both.” Required Coursework in Psychological Testing and Psychopharmacology: Business & Professions Code 4980.41(f) requires qualifying master's or doctor's degree programs leading to the MFT license to contain survey courses in psychopharmacology. These courses will be required only for those persons who begin graduate study on or after January 1, 2001. Anyone currently in the pipeline will not be affected by this new requirement. In regards to recordkeeping, 2. Interns are not to be supervised by anyone with whom they have a personal relationship. Nor should interns receive supervision from their psychotherapists. the failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered is considered unprofessional conduct. No person may, for remuneration, engage in the practice of marriage and family therapy or social work as defined by Section 4980.02, unless he or she holds a valid license as a Marriage and Family Therapist or social worker, or unless he is specifically exempted from such requirement, nor may he advertise himself or herself as performing the services of a marriage, family, child, domestic, or marital consultant, or in any way use these or any similar titles to imply that he or she performs these services without a license as provided by this chapter.
January 19, 2010
Alchoholism and Substance Abuse Dependancy
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.
1. Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes. 2. Define substance abuse and identify its efftects. 3. Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency. 4. Apply current theories of the etiology of substance abuse. 5. Recognize the role of persons and systems that support or compound the abuse. 6. Become familiar with the major treatment approaches to alcoholism and chemical dependency. 7. Learn the national legal aspects of substance abuse. 8. Obtain knowledge of certain populations at risk with regard to substance abuse. 9. Access community resources offering assessment, treatment and follow-up for the abuser and family. 10. Learn the process of referring affected persons.
Table of Contents: 1. Definitions 2. History 3. DSM Criteria 4. Types of Substance Abuse 5. Prescription Drug Addiction and Dependence 6. Demographic Characteristics 7. Substance Abuse Treatment and Outcomes 8. References
1. DEFINITIONS
Substance abuse is defined as “the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. It is characterized by a pattern of continued pathological use of a medication, non-medically indicated substance, drug or toxin, that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. Some controversy exists regarding the precise distinctions between substance abuse and substance dependence. However, the current clinical standard distinguishes between them by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use. Substance abuse may lead to addiction or substance dependence. Dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse. However, abuse frequently occurs without dependence. Dependence involves added physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.”
2. HISTORY
Throughout history, in fact for thousands of years, substance abuse has existed. Early Egyptians drank wine while narcotics were used dating back to 4000 B.C. Medicinal use of marijuana has been dated back to 2737 B.C. in China. During the 19th century, the active substances in drugs began to be extracted. At that time, substances including morphine, laudanum, and cocaine were unregulated and prescribed by physicians for a variety of illnesses. During the American Civil War, morphine was commonly used, and wounded veterans returned home with morphine kits and hypodermic needles. Opium dens grew and by the early 1900s there were an estimated 250,000 addicts in the United States (Office of Applied Studies, Substance Abuse and Mental Health Services Administration). The problems of addiction became gradually identified. Legal measures against drug abuse in the United States were first established in 1875, when opium dens were outlawed in San Francisco. The first national drug law was the Pure Food and Drug Act of 1906, which required accurate labeling of patent medicines containing opium and certain other drugs. In 1914 the Harrison Narcotic Act forbade sale of substantial doses of opiates or cocaine except by licensed doctors and pharmacies. Later, heroin was totally banned. Subsequent Supreme Court decisions made it illegal for doctors to prescribe any narcotic to addicts; many doctors who prescribed maintenance doses as part of an addiction treatment plan were jailed, and soon all attempts at treatment were abandoned. Use of narcotics and cocaine diminished by the 1920s. The spirit of temperance led to the prohibition of alcohol by the Eighteenth Amendment to the Constitution in 1919, but Prohibition was repealed in 1933. In the 1930s most states required antidrug education in the schools, but fears that knowledge would lead to experimentation caused it to be abandoned in most places. Soon after the repeal of Prohibition, the U.S. Federal Bureau of Narcotics (now the Drug Enforcement Administration) began a campaign to portray marijuana as a powerful, addicting substance that would lead users into narcotics addiction. In the 1950s, use of marijuana increased again, along with that of amphetamines and tranquilizers. The social upheaval of the 1960s brought with it a dramatic increase in drug use and some increased social acceptance; by the early 1970s some states and localities had decriminalized marijuana and lowered drinking ages. The 1980s brought a decline in the use of most drugs, but cocaine and crack use soared. The military became involved in border patrols for the first time, and troops invaded Panama and brought its de facto leader, Manuel Noriega, to trial for drug trafficking (Office of Applied Studies, Substance Abuse and Mental Health Services Administration). Throughout the years, the public's perception of the dangers of specific substances changed. The surgeon general's warning label on tobacco packaging gradually made people aware of the addictive nature of nicotine. By 1995, the Food and Drug Administration was considering its regulation. The recognition of fetal alcohol syndrome brought warning labels to alcohol products. The addictive nature of prescription drugs such as diazepam (Valium) became known, and caffeine came under scrutiny as well. Drug laws have tried to keep up with the changing perceptions and real dangers of substance abuse. By 1970 over 55 federal drug laws and countless state laws specified a variety of punitive measures, including life imprisonment and
even the death penalty. To clarify the situation, the Comprehensive Drug Abuse Prevention and Control Act of 1970 repealed, replaced, or updated all previous federal laws concerned with narcotics and all other dangerous drugs. While possession was made illegal, the severest penalties were reserved for illicit distribution and manufacture of drugs. The act dealt with prevention and treatment of drug abuse as well as control of drug traffic. The Anti-Drug Abuse Acts of 1986 and 1988 increased funding for treatment and rehabilitation; the 1988 act created the Office of National Drug Control Policy. Its director, often referred to as the drug “czar,” is responsible for coordinating national drug control policy (Office of Applied Studies, Substance Abuse and Mental Health Services Administration).
1. Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes. 2. Define substance abuse and identify its efftects. 3. Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency. 4. Apply current theories of the etiology of substance abuse. 5. Recognize the role of persons and systems that support or compound the abuse. 6. Become familiar with the major treatment approaches to alcoholism and chemical dependency. 7. Learn the national legal aspects of substance abuse. 8. Obtain knowledge of certain populations at risk with regard to substance abuse. 9. Access community resources offering assessment, treatment and follow-up for the abuser and family. 10. Learn the process of referring affected persons.
Table of Contents: 1. Definitions 2. History 3. DSM Criteria 4. Types of Substance Abuse 5. Prescription Drug Addiction and Dependence 6. Demographic Characteristics 7. Substance Abuse Treatment and Outcomes 8. References
1. DEFINITIONS
Substance abuse is defined as “the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. It is characterized by a pattern of continued pathological use of a medication, non-medically indicated substance, drug or toxin, that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. Some controversy exists regarding the precise distinctions between substance abuse and substance dependence. However, the current clinical standard distinguishes between them by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use. Substance abuse may lead to addiction or substance dependence. Dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse. However, abuse frequently occurs without dependence. Dependence involves added physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.”
2. HISTORY
Throughout history, in fact for thousands of years, substance abuse has existed. Early Egyptians drank wine while narcotics were used dating back to 4000 B.C. Medicinal use of marijuana has been dated back to 2737 B.C. in China. During the 19th century, the active substances in drugs began to be extracted. At that time, substances including morphine, laudanum, and cocaine were unregulated and prescribed by physicians for a variety of illnesses. During the American Civil War, morphine was commonly used, and wounded veterans returned home with morphine kits and hypodermic needles. Opium dens grew and by the early 1900s there were an estimated 250,000 addicts in the United States (Office of Applied Studies, Substance Abuse and Mental Health Services Administration). The problems of addiction became gradually identified. Legal measures against drug abuse in the United States were first established in 1875, when opium dens were outlawed in San Francisco. The first national drug law was the Pure Food and Drug Act of 1906, which required accurate labeling of patent medicines containing opium and certain other drugs. In 1914 the Harrison Narcotic Act forbade sale of substantial doses of opiates or cocaine except by licensed doctors and pharmacies. Later, heroin was totally banned. Subsequent Supreme Court decisions made it illegal for doctors to prescribe any narcotic to addicts; many doctors who prescribed maintenance doses as part of an addiction treatment plan were jailed, and soon all attempts at treatment were abandoned. Use of narcotics and cocaine diminished by the 1920s. The spirit of temperance led to the prohibition of alcohol by the Eighteenth Amendment to the Constitution in 1919, but Prohibition was repealed in 1933. In the 1930s most states required antidrug education in the schools, but fears that knowledge would lead to experimentation caused it to be abandoned in most places. Soon after the repeal of Prohibition, the U.S. Federal Bureau of Narcotics (now the Drug Enforcement Administration) began a campaign to portray marijuana as a powerful, addicting substance that would lead users into narcotics addiction. In the 1950s, use of marijuana increased again, along with that of amphetamines and tranquilizers. The social upheaval of the 1960s brought with it a dramatic increase in drug use and some increased social acceptance; by the early 1970s some states and localities had decriminalized marijuana and lowered drinking ages. The 1980s brought a decline in the use of most drugs, but cocaine and crack use soared. The military became involved in border patrols for the first time, and troops invaded Panama and brought its de facto leader, Manuel Noriega, to trial for drug trafficking (Office of Applied Studies, Substance Abuse and Mental Health Services Administration). Throughout the years, the public's perception of the dangers of specific substances changed. The surgeon general's warning label on tobacco packaging gradually made people aware of the addictive nature of nicotine. By 1995, the Food and Drug Administration was considering its regulation. The recognition of fetal alcohol syndrome brought warning labels to alcohol products. The addictive nature of prescription drugs such as diazepam (Valium) became known, and caffeine came under scrutiny as well. Drug laws have tried to keep up with the changing perceptions and real dangers of substance abuse. By 1970 over 55 federal drug laws and countless state laws specified a variety of punitive measures, including life imprisonment and
even the death penalty. To clarify the situation, the Comprehensive Drug Abuse Prevention and Control Act of 1970 repealed, replaced, or updated all previous federal laws concerned with narcotics and all other dangerous drugs. While possession was made illegal, the severest penalties were reserved for illicit distribution and manufacture of drugs. The act dealt with prevention and treatment of drug abuse as well as control of drug traffic. The Anti-Drug Abuse Acts of 1986 and 1988 increased funding for treatment and rehabilitation; the 1988 act created the Office of National Drug Control Policy. Its director, often referred to as the drug “czar,” is responsible for coordinating national drug control policy (Office of Applied Studies, Substance Abuse and Mental Health Services Administration).
Child Abuse Assessment and Reporting
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.
1. Assess child abuse risk factors 2. Evaluate the need for a Suspected Child Abuse Report 3. Become familiar with relevant child abuse statistics 4. Differentiate between the roles of mandated and non-mandated reporters 5. Identify the symptoms and warning signs of child abuse 6. Utilize applicable clinical assessment and treatment tools 7. Utilize applicable treatment interventions 8. Identify and have accessibility to relevant resources Table of Contents: 1. Definition 2. History and the Law 3. Types of Child Abuse 4. Statistics 5. Mandated Reporters 6. Child Abuse Symptoms 7. Clinical Assessment 8. Treatment 9. Resources 10. References 1.
Definition
Child abuse is the physical, psychological or sexual maltreatment of children. The
Centers for Disease Control and Prevention (CDC) defines child maltreatment as “any act or series of acts or commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child”. Most child abuse occurs in the home, with a lesser amount occurring in the organizations, schools or community organizations. Currently, there are four widely recognized and identifiable categories of child abuse including neglect, physical abuse, psychological/emotional abuse, and sexual abuse. Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. The Mental Health Journal defines child as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm.”
2. History and the Law
Child sexual abuse is illegal in every civilized society with consequences often including severe criminal penalties, and in some jurisdictions, life imprisonment or capital punishment. A legal adult's sexual intercourse with a child below the legal age of consent is defined as statutory rape, based on the principle that a child is not capable of consent and that any apparent consent by a child is of course not considered to be legal consent. The United Nations Convention on the Rights of the Child (CRC) is an international treaty that legally obliges states to protect children's rights. Articles 34 and 35 of the CRC require states to protect children from all forms of sexual exploitation and sexual abuse. This includes outlawing the coercion of a child to perform sexual activity, the prostitution of children, and the exploitation of children in creating pornography. States are also required to prevent the abduction, sale, or trafficking of children. As of November 2008, 193 countries are bound by the CRC, including every member of the United Nations except the United States and Somalia. Child sexual abuse has gained increased public attention throughout the past few decades and has become one of the most high-profile crimes. Since the 1970s the sexual abuse of children and child molestation has increasingly been recognized as deeply damaging to children and thus unacceptable for society as a whole. While sexual use of children by adults has existed throughout history, it has only become the object of significant public attention in recent times. The first published work dedicated specifically to child sexual abuse appeared in France in 1857: Medical-Legal Studies of Sexual Assault (Etude Médico-Légale sur les Attentats aux Moeurs), by Auguste Ambroise Tardieu, the noted French pathologist and pioneer of forensic medicine (Masson, 1984, pp. 15–25). Prior to the 1970’s and 1980’s, sexual abuse remained secretive and socially unspeakable. Studies on child molestation did not emerge until the 1920s and the first national estimate of the number of child sexual abuse cases was published in 1948. By 1968 44 out of 50 U.S. states had enacted mandatory laws that required physicians to report cases of suspicious child abuse. Legal action began to become more prevalent in the 1970s with the enactment of the Child Abuse Prevention and Treatment Act in 1974 in conjunction with the creation of the National Center for Child Abuse and Neglect. Since the creation of the Child Abuse and Treatment Act, reported child abuse cases have increased dramatically. Finally, the National Abuse Coalition was created in 1979 to create pressure in congress to create more sexual abuse laws. Feminism contributed to increased awareness of child sexual abuse and violence against women, and made them public, political issues. Judith Lewis Herman, Harvard professor of psychiatry, wrote the first book ever on father-daughter incest when she discovered during her medical residency that a large number of the women she was seeing had been victims of father-daughter incest. Herman notes that her approach to her clinical experience grew out of her involvement in the civil rights movement. Her second book Trauma and Recovery, considered a classic and ground-breaking work coined the term complex post-traumatic stress disorder. "In it she defines this concept not only in terms of prolonged trauma, but in terms of what she calls "subjection to totalitarian control." Examples of this concept include:...hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation (In 1986, Congress passed the Child Abuse Victims' Rights Act, which allowed victims a civil claim in sexual abuse cases. The number of laws created in the 1980s and 1990s began to create greater prosecution and detection of child sexual abuse perpetrators. During the 1970s a large transition began in the legislature related to child sexual abuse. Megan's Law which was enacted in 2004, gives the public access to knowledge and identification of sex offenders nationwide. Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one history's largest social revolutions." According to John Jay College of Criminal Justice professor B.J. Cling, "By the early 21st century, the issue of child sexual abuse has become a legitimate focus of professional attention, while increasingly separated from second wave feminism...As child sexual abuse becomes absorbed into the larger field of interpersonal trauma studies, child sexual abuse studies and intervention strategies have become degendered and largely unaware of their political origins in modern feminism and other vibrant political movements of the 1970s. One may hope that unlike in the past, this rediscovery of child sexual abuse that began in the 70s will not again be followed by collective amnesia. The institutionalization of child maltreatment interventions in federally funded centers, national and international societies, and a host of research studies (in which the United States continues to lead the world) offers grounds for cautious optimism. Nevertheless, as Judith Herman argues cogently, 'The systematic study of psychological trauma...depends on the support of a political movement.'" Herman, Judith Lewis, 1997. Trauma and recovery: The aftermath of violence from domestic abuse to political terror. Basic Books). Increasing awareness of child sexual abuse in the United States has ignited civil lawsuits for monetary damages. Increased awareness of child sexual abuse has also encouraged more victims to step forward, whereas in the past victims were often secretive about their abuse. Some states have enacted specific laws lengthening the applicable statutes of limitations so as to allow victims of child sexual abuse to file suit sometimes years after they have reached the age of majority. Such lawsuits can be brought where a person or entity, such as a school, church or youth organization, was charged with supervising the child but failed to do so with child sexual abuse resulting. In the Catholic sex abuse cases the various Roman Catholic Dioceses in the
United States have paid out approximately $1 billion settling hundreds of these lawsuits since the early 1990s. Due to the fact that lawsuits often involve demanding procedures, concern exists that children or adults who file suit will be re-victimized by defendants through the legal process. The child sexual abuse plaintiff's attorney Thomas A. Cifarelli has written that children involved in the legal system, particularly victims of sexual abuse and molestation, should be afforded certain procedural safeguards to protect them from harassment during the legal process. A 2000 World Health Organization Geneva report, “World Report on Violence and Health (Chap 6 - Sexual Violence)” states, “Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a teacher and a pupil is not a serious disciplinary offence and policies on sexual harassment in schools either do not exist or are not implemented. In recent years, though, some countries have introduced laws prohibiting sexual relations between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of curricula, so as to transform gender relations in schools.” 3. Types of Child Abuse • Neglect, in which the responsible adult fails to adequately provide for various needs, including physical (failure to provide adequate food, clothing, or hygiene), emotional (failure to provide nurturing or affection) or educational (failure to enroll a child in school). • Physical abuse is physical aggression directed at a child by an adult. It can involve striking, burning, choking or shaking a child, and the distinction between discipline and abuse is often poorly defined. The transmission of toxins to a child through their mother (such as with fetal alcohol syndrome) can also be considered physical abuse in some jurisdictions. • Child sexual abuse is any sexual act between an adult and a child, including penetration, fondling, exposure to adult sexuality and violations of privacy. • Psychological abuse, also known as emotional abuse, which can involve belittling or shaming a child, inappropriate or extreme punishment and the withholding of affection.
Physical Abuse
Physical abuse is abuse involving contact intended to cause feelings of intimidation, pain, injury, or other physical suffering or harm. Forms of physical abuse include: • striking • punching • pushing, pulling • slapping • Whipping • striking with an object • locking in or out of a room or place/false imprisonment • excessive pinching • kicking • having someone fall • kneeing • strangling • head butting • drowning • sleep deprivation • exposure to cold, freezing • exposure to heat or radiation, burning • exposure to electric shock • placing in "stress positions" (tied or otherwise forced) • cutting or otherwise exposing somebody to something sharp • exposure to a dangerous animal • throwing or shooting a projectile • exposure to a toxic substance • infecting with a disease • withholding food or medication • assault • bodily harm • humiliation • torture
1. Assess child abuse risk factors 2. Evaluate the need for a Suspected Child Abuse Report 3. Become familiar with relevant child abuse statistics 4. Differentiate between the roles of mandated and non-mandated reporters 5. Identify the symptoms and warning signs of child abuse 6. Utilize applicable clinical assessment and treatment tools 7. Utilize applicable treatment interventions 8. Identify and have accessibility to relevant resources Table of Contents: 1. Definition 2. History and the Law 3. Types of Child Abuse 4. Statistics 5. Mandated Reporters 6. Child Abuse Symptoms 7. Clinical Assessment 8. Treatment 9. Resources 10. References 1.
Definition
Child abuse is the physical, psychological or sexual maltreatment of children. The
Centers for Disease Control and Prevention (CDC) defines child maltreatment as “any act or series of acts or commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child”. Most child abuse occurs in the home, with a lesser amount occurring in the organizations, schools or community organizations. Currently, there are four widely recognized and identifiable categories of child abuse including neglect, physical abuse, psychological/emotional abuse, and sexual abuse. Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. The Mental Health Journal defines child as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm.”
2. History and the Law
Child sexual abuse is illegal in every civilized society with consequences often including severe criminal penalties, and in some jurisdictions, life imprisonment or capital punishment. A legal adult's sexual intercourse with a child below the legal age of consent is defined as statutory rape, based on the principle that a child is not capable of consent and that any apparent consent by a child is of course not considered to be legal consent. The United Nations Convention on the Rights of the Child (CRC) is an international treaty that legally obliges states to protect children's rights. Articles 34 and 35 of the CRC require states to protect children from all forms of sexual exploitation and sexual abuse. This includes outlawing the coercion of a child to perform sexual activity, the prostitution of children, and the exploitation of children in creating pornography. States are also required to prevent the abduction, sale, or trafficking of children. As of November 2008, 193 countries are bound by the CRC, including every member of the United Nations except the United States and Somalia. Child sexual abuse has gained increased public attention throughout the past few decades and has become one of the most high-profile crimes. Since the 1970s the sexual abuse of children and child molestation has increasingly been recognized as deeply damaging to children and thus unacceptable for society as a whole. While sexual use of children by adults has existed throughout history, it has only become the object of significant public attention in recent times. The first published work dedicated specifically to child sexual abuse appeared in France in 1857: Medical-Legal Studies of Sexual Assault (Etude Médico-Légale sur les Attentats aux Moeurs), by Auguste Ambroise Tardieu, the noted French pathologist and pioneer of forensic medicine (Masson, 1984, pp. 15–25). Prior to the 1970’s and 1980’s, sexual abuse remained secretive and socially unspeakable. Studies on child molestation did not emerge until the 1920s and the first national estimate of the number of child sexual abuse cases was published in 1948. By 1968 44 out of 50 U.S. states had enacted mandatory laws that required physicians to report cases of suspicious child abuse. Legal action began to become more prevalent in the 1970s with the enactment of the Child Abuse Prevention and Treatment Act in 1974 in conjunction with the creation of the National Center for Child Abuse and Neglect. Since the creation of the Child Abuse and Treatment Act, reported child abuse cases have increased dramatically. Finally, the National Abuse Coalition was created in 1979 to create pressure in congress to create more sexual abuse laws. Feminism contributed to increased awareness of child sexual abuse and violence against women, and made them public, political issues. Judith Lewis Herman, Harvard professor of psychiatry, wrote the first book ever on father-daughter incest when she discovered during her medical residency that a large number of the women she was seeing had been victims of father-daughter incest. Herman notes that her approach to her clinical experience grew out of her involvement in the civil rights movement. Her second book Trauma and Recovery, considered a classic and ground-breaking work coined the term complex post-traumatic stress disorder. "In it she defines this concept not only in terms of prolonged trauma, but in terms of what she calls "subjection to totalitarian control." Examples of this concept include:...hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation (In 1986, Congress passed the Child Abuse Victims' Rights Act, which allowed victims a civil claim in sexual abuse cases. The number of laws created in the 1980s and 1990s began to create greater prosecution and detection of child sexual abuse perpetrators. During the 1970s a large transition began in the legislature related to child sexual abuse. Megan's Law which was enacted in 2004, gives the public access to knowledge and identification of sex offenders nationwide. Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one history's largest social revolutions." According to John Jay College of Criminal Justice professor B.J. Cling, "By the early 21st century, the issue of child sexual abuse has become a legitimate focus of professional attention, while increasingly separated from second wave feminism...As child sexual abuse becomes absorbed into the larger field of interpersonal trauma studies, child sexual abuse studies and intervention strategies have become degendered and largely unaware of their political origins in modern feminism and other vibrant political movements of the 1970s. One may hope that unlike in the past, this rediscovery of child sexual abuse that began in the 70s will not again be followed by collective amnesia. The institutionalization of child maltreatment interventions in federally funded centers, national and international societies, and a host of research studies (in which the United States continues to lead the world) offers grounds for cautious optimism. Nevertheless, as Judith Herman argues cogently, 'The systematic study of psychological trauma...depends on the support of a political movement.'" Herman, Judith Lewis, 1997. Trauma and recovery: The aftermath of violence from domestic abuse to political terror. Basic Books). Increasing awareness of child sexual abuse in the United States has ignited civil lawsuits for monetary damages. Increased awareness of child sexual abuse has also encouraged more victims to step forward, whereas in the past victims were often secretive about their abuse. Some states have enacted specific laws lengthening the applicable statutes of limitations so as to allow victims of child sexual abuse to file suit sometimes years after they have reached the age of majority. Such lawsuits can be brought where a person or entity, such as a school, church or youth organization, was charged with supervising the child but failed to do so with child sexual abuse resulting. In the Catholic sex abuse cases the various Roman Catholic Dioceses in the
United States have paid out approximately $1 billion settling hundreds of these lawsuits since the early 1990s. Due to the fact that lawsuits often involve demanding procedures, concern exists that children or adults who file suit will be re-victimized by defendants through the legal process. The child sexual abuse plaintiff's attorney Thomas A. Cifarelli has written that children involved in the legal system, particularly victims of sexual abuse and molestation, should be afforded certain procedural safeguards to protect them from harassment during the legal process. A 2000 World Health Organization Geneva report, “World Report on Violence and Health (Chap 6 - Sexual Violence)” states, “Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a teacher and a pupil is not a serious disciplinary offence and policies on sexual harassment in schools either do not exist or are not implemented. In recent years, though, some countries have introduced laws prohibiting sexual relations between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of curricula, so as to transform gender relations in schools.” 3. Types of Child Abuse • Neglect, in which the responsible adult fails to adequately provide for various needs, including physical (failure to provide adequate food, clothing, or hygiene), emotional (failure to provide nurturing or affection) or educational (failure to enroll a child in school). • Physical abuse is physical aggression directed at a child by an adult. It can involve striking, burning, choking or shaking a child, and the distinction between discipline and abuse is often poorly defined. The transmission of toxins to a child through their mother (such as with fetal alcohol syndrome) can also be considered physical abuse in some jurisdictions. • Child sexual abuse is any sexual act between an adult and a child, including penetration, fondling, exposure to adult sexuality and violations of privacy. • Psychological abuse, also known as emotional abuse, which can involve belittling or shaming a child, inappropriate or extreme punishment and the withholding of affection.
Physical Abuse
Physical abuse is abuse involving contact intended to cause feelings of intimidation, pain, injury, or other physical suffering or harm. Forms of physical abuse include: • striking • punching • pushing, pulling • slapping • Whipping • striking with an object • locking in or out of a room or place/false imprisonment • excessive pinching • kicking • having someone fall • kneeing • strangling • head butting • drowning • sleep deprivation • exposure to cold, freezing • exposure to heat or radiation, burning • exposure to electric shock • placing in "stress positions" (tied or otherwise forced) • cutting or otherwise exposing somebody to something sharp • exposure to a dangerous animal • throwing or shooting a projectile • exposure to a toxic substance • infecting with a disease • withholding food or medication • assault • bodily harm • humiliation • torture
January 18, 2010
HIV and AIDS Continuing Education CEUS
HIV and AIDS Continuing Education
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material
may be transmitted or reproduced in any form, or by any means, mechanical or
electronic without written permission of Aspira Continuing Education.
1. Differentiate between HIV and AIDS
2. Identify causes
3. Learn epidemiology
4. Learn the historical framework related to the development of
HIV/AIDS
5. Become familiar with the impact HIV/AIDS on culture
6. Identify and recognize common stigmas associated with HIV/AIDS
7. Increase familiarity with the relationship between HIV/AIDS and
mental health
8. Increase familiarity with the relationship between HIV/AIDS and
substance abuse
9. Develop the ability to identify the characteristics and method of
assessment and treatment of people who live with HIV/AIDS.
Table of Contents:
1. Definitions
2. Causes
3. Epidemiology
2
4. History
5. Stigma
6. HIV/AIDS and Mental Health
7. HIV/AIDS and Substance Abuse
8. Cognitive Disorders
9. Summary
10. References
1. Definitions
Human immunodeficiency virus (HIV) is a lentivirus (a member of the
retrovirus family) that can lead to acquired immunodeficiency syndrome
(AIDS), a condition in humans in which the immune system begins to fail,
leading to life-threatening opportunistic infections. Previous names for the
virus include human T-lymphotropic virus-III (HTLV-III),
lymphadenopathy-associated virus (LAV), and AIDS-associated retrovirus
(ARV). Infection with HIV occurs by the transfer of blood, semen, vaginal
fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present
as both free virus particles and virus within infected immune cells. The four
major routes of transmission are unprotected sexual intercourse,
contaminated needles, breast milk, and transmission from an infected mother
to her baby at birth (Vertical transmission). Screening of blood products for
HIV has largely eliminated transmission through blood transfusions or
infected blood products in the developed world (Appay V, Sauce D, January
2008. "Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
HIV infection in humans is now pandemic. As
of January 2006, the Joint United Nations
Programme on HIV/AIDS (UNAIDS) and the
World Health Organization (WHO) estimate that
AIDS has killed more than 25 million people
since it was first recognized on December 1,
1981. It is estimated that about 0.6 percent of the
world's population is infected with HIV. In
2005 alone, AIDS claimed an estimated 2.4–3.3
million lives, of which more than 570,000 were
children. A third of these deaths are occurring in
sub-Saharan Africa, retarding economic growth
and increasing poverty. According to current
estimates, HIV is set to infect 90 million people
in Africa, resulting in a minimum estimate of 18 million orphans.
Antiretroviral treatment reduces both the mortality and the morbidity of HIV
infection, but routine access to antiretroviral medication is not available in
all countries. HIV primarily infects vital cells in the human immune system
such as helper T cells (specifically CD4+ T cells), macrophages, and
Human
immunodeficiency virus
Scanning electron micrograph
of HIV-1 (in green) budding
from cultured lymphocyte.
Multiple round bumps on cell
surface represent sites of
assembly and budding of
virions.
dendritic cells. HIV infection leads to low levels of CD4+ T cells through
three main mechanisms: firstly, direct viral killing of infected cells;
secondly, increased rates of apoptosis in infected cells; and thirdly, killing of
infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected
cells. When CD4+ T cell numbers decline below a critical level, cellmediated
immunity is lost, and the body becomes progressively more
susceptible to opportunistic infections (Appay V, Sauce D, January 2008.
"Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Eventually most HIV-infected individuals develop AIDS (Acquired
Immunodeficiency Syndrome). These individuals mostly die from
opportunistic infections or malignancies associated with the progressive
failure of the immune system. Without treatment, about 9 out of every 10
persons with HIV will progress to AIDS after 10-15 years. Many people
deteriorate much sooner. Treatment with anti-retrovirals increases the life
expectancy of people infected with HIV. Even after HIV has progressed to
diagnosable AIDS, the average survival time with antiretroviral therapy (as
of 2005) is estimated to be more than 5 years. Without antiretroviral therapy,
death normally occurs within a year. It is hoped that current and future
treatments may allow HIV-infected individuals to achieve a life expectancy
approaching that of the general public (Appay V, Sauce D, January 2008.
"Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Acquired immune deficiency syndrome or acquired immunodeficiency
syndrome (AIDS) is a set of symptoms and infections resulting from the
damage to the human immune system caused by the human
immunodeficiency virus (HIV). This condition progressively reduces the
effectiveness of the immune system and leaves individuals susceptible to
opportunistic infections and tumors. HIV is transmitted through direct
contact of a mucous membrane or the bloodstream with a bodily fluid
containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and
breast milk (Appay V, Sauce D (January 2008). "Immune activation and
inflammation in HIV-1 infection: causes and consequences". J. Pathol.)
This transmission can involve anal, vaginal or oral sex, blood transfusion,
contaminated hypodermic needles, exchange between mother and baby
during pregnancy, childbirth, or breastfeeding, or other exposure to one of
the above bodily fluids (Appay V, Sauce D, January 2008. "Immune
activation and inflammation in HIV-1 infection: causes and consequences".
J. Pathol).
AIDS is now a pandemic. In 2007, an estimated 33.2 million people lived
with the disease worldwide, and it killed an estimated 2.1 million people,
including 330,000 children. Over three-quarters of these deaths occurred in
sub-Saharan Africa, retarding economic growth and destroying human
capital. Genetic research indicates that HIV originated in west-central
Africa during the late nineteenth or early twentieth century. AIDS was first
recognized by the U.S. Centers for Disease Control and Prevention in 1981
and its cause, HIV, identified in the early 1980s (Appay V, Sauce D, January
2008. "Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Although treatments for AIDS and HIV can slow the course of the disease,
there is currently no vaccine or cure. Antiretroviral treatment reduces both
the mortality and the morbidity of HIV infection, but these drugs are
expensive and routine access to antiretroviral medication is not available in
all countries. Due to the difficulty in treating HIV infection, preventing
infection is a key aim in controlling the AIDS epidemic, with health
organizations promoting safe sex and needle-exchange programs in attempts
to slow the spread of the virus (Appay V, Sauce D, January 2008. "Immune
activation and inflammation in HIV-1 infection: causes and consequences".
J. Pathol).
2. Causes
AIDS is the most severe acceleration of infection with HIV. HIV is a
retrovirus that primarily infects vital organs of the human immune system
such as CD4+ T cells (a subset of T cells), macrophages and dendritic cells.
It directly and indirectly destroys CD4+ T cells. Once HIV has killed so
many CD4+ T cells that there are fewer than 200 of these cells per microliter
(µL) of blood, cellular immunity is lost. Acute HIV infection progresses
over time to clinical latent HIV infection and then to early symptomatic HIV
infection and later to AIDS, which is identified either on the basis of the
amount of CD4+ T cells remaining in the blood, and/or the presence of
certain infections (Appay V, Sauce D, January 2008. "Immune activation
and inflammation in HIV-1 infection: causes and consequences". J. Pathol).
Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte.
In the absence of antiretroviral therapy, the median time of progression from
HIV infection to AIDS is nine to ten years, and the median survival time
after developing AIDS is only 9.2 months. However, the rate of clinical
disease progression varies widely between individuals, from two weeks up
to 20 years. Many factors affect the rate of progression. These include
factors that influence the body's ability to defend against HIV such as the
infected person's general immune function. Older people have weaker
immune systems, and therefore have a greater risk of rapid disease
progression than younger people. Poor access to health care and the
existence of coexisting infections such as tuberculosis also may predispose
people to faster disease progression. The infected person's genetic
inheritance plays an important role and some people are resistant to certain
strains of HIV. An example of this is people with the homozygous CCR5-
Δ32 variation are resistant to infection with certain strains of HIV. HIV is
genetically variable and exists as different strains, which cause different
rates of clinical disease progression (Mastro TD, de Vincenzi I, 1996.
Probabilities of sexual HIV-1 transmission).
Sexual transmission
Sexual transmission occurs with the contact between sexual secretions of
one person with the rectal, genital or oral mucous membranes of another.
Unprotected receptive sexual acts are riskier than unprotected insertive
sexual acts, and the risk for transmitting HIV through unprotected anal
intercourse is greater than the risk from vaginal intercourse or oral sex.
However, oral sex is not entirely safe, as HIV can be transmitted through
both insertive and receptive oral sex. Sexual assault greatly increases the risk
of HIV transmission as protection is rarely employed and physical trauma to
the vagina occurs frequently, facilitating the transmission of HIV. Other
sexually transmitted infections (STI) increase the risk of HIV transmission
and infection, because they cause the disruption of the normal epithelial
barrier by genital ulceration and/or microulceration; and by accumulation of
pools of HIV-susceptible or HIV-infected cells (lymphocytes and
macrophages) in semen and vaginal secretions. Epidemiological studies
from sub-Saharan Africa, Europe and North America suggest that genital
ulcers, such as those caused by syphilis and/or chancroid, increase the risk of
becoming infected with HIV by about fourfold. There is also a significant
although lesser increase in risk from STIs such as gonorrhea, Chlamydial
infection and trichomoniasis, which all cause local accumulations of
lymphocytes and macrophages (Mastro TD, de Vincenzi I, 1996.
Probabilities of sexual HIV-1 transmission).
Transmission of HIV depends on the infectiousness of the index case and the
susceptibility of the uninfected partner. Infectivity seems to vary during the
course of illness and is not constant between individuals. An undetectable
plasma viral load does not necessarily indicate a low viral load in the
seminal liquid or genital secretions. However, each 10-fold increase in the
level of HIV in the blood is associated with an 81% increased rate of HIV
transmission. Women are more susceptible to HIV-1 infection due to
hormonal changes, vaginal microbial ecology and physiology, and a higher
prevalence of sexually transmitted diseases. People who have been infected
with one strain of HIV can still be infected later on in their lives by other,
more virulent strains. Infection is unlikely in a single encounter. High rates
of infection have been linked to a pattern of overlapping long-term romantic
relationships. This allows the virus to quickly spread to multiple partners
who in turn infect their partners. A pattern of serial monogamy or occasional
casual encounters is associated with lower rates of infection. HIV spreads
readily through heterosexual sex in Africa, but less so elsewhere. One
possibility being researched is that schistosomiasis, which affects up to 50
per cent of women in parts of Africa, damages the lining of the vagina
(Mastro TD, de Vincenzi I, 1996. "Probabilities of sexual HIV-1
transmission).
Exposure to blood-borne pathogens
(CDC poster from 1989 highlighting the threat of AIDS associated with drug use)
This transmission route is particularly relevant to intravenous drug users,
hemophiliacs and recipients of blood transfusions and blood products.
Sharing and reusing syringes contaminated with HIV-infected blood
represents a major risk for infection with HIV. Needle sharing is the cause
of one third of all new HIV-infections in North America, China, and Eastern
Europe. The risk of being infected with HIV from a single prick with a
needle that has been used on an HIV-infected person is thought to be about 1
in 150. Post-exposure prophylaxis with anti-HIV drugs can further reduce
this risk. This route can also affect people who give and receive tattoos and
piercings. Universal precautions are frequently not followed in both sub-
Saharan Africa and much of Asia because of both a shortage of supplies and
inadequate training. The WHO estimates that approximately 2.5% of all HIV
infections in sub-Saharan Africa are transmitted through unsafe healthcare
injections. Because of this, the United Nations General Assembly has urged
the nations of the world to implement precautions to prevent HIV
transmission by health workers. The risk of transmitting HIV to blood
transfusion recipients is extremely low in developed countries where
improved donor selection and HIV screening is performed. However,
according to the WHO, the overwhelming majority of the world's population
does not have access to safe blood and between 5% and 10% of the world's
9
9
HIV infections come from transfusion of infected blood and blood products
(Source: The World Health Organization).
Perinatal transmission
The transmission of the virus from the mother to the child can occur in utero
during the last weeks of pregnancy and at childbirth. In the absence of
treatment, the transmission rate between a mother and her child during
pregnancy, labor and delivery is 25%. However, when the mother takes
antiretroviral therapy and gives birth by caesarean section, the rate of
transmission is just 1%. The risk of infection is influenced by the viral load
of the mother at birth, with the higher the viral load, the higher the risk.
Breastfeeding also increases the risk of transmission by about 4 % (Source:
The World Health Organization).
Misconceptions
A number of misconceptions have arisen surrounding HIV/AIDS. Three of
the most common are that AIDS can spread through casual contact, that
sexual intercourse with a virgin will cure AIDS, and that HIV can infect
only homosexual men and drug users. Other misconceptions are that any act
of anal intercourse between gay men can lead to AIDS infection, and that
open discussion of homosexuality and HIV in schools will lead to increased
rates of homosexuality and AIDS (Source: The World Health
Organization).
Pathophysiology
The pathophysiology of AIDS is complex, as is the case with all syndromes.
Ultimately, HIV causes AIDS by depleting CD4+ T helper lymphocytes.
This weakens the immune system and allows opportunistic infections. T
lymphocytes are essential to the immune response and without them, the
body cannot fight infections or kill cancerous cells. The mechanism of CD4+
T cell depletion differs in the acute and chronic phases.
10
10
During the acute phase, HIVinduced
cell lysis and killing of
infected cells by cytotoxic T cells
accounts for CD4+ T cell
depletion, although apoptosis may
also be a factor. During the
chronic phase, the consequences
of generalized immune activation
coupled with the gradual loss of
the ability of the immune system
to generate new T cells appear to
account for the slow decline in
CD4+ T cell numbers.
Although the symptoms of
immune deficiency characteristic
of AIDS do not appear for years
after a person is infected, the bulk
of CD4+ T cell loss occurs during
the first weeks of infection,
especially in the intestinal
mucosa, which harbors the
majority of the lymphocytes
found in the body. The reason for
the preferential loss of mucosal
CD4+ T cells is that a majority of
mucosal CD4+ T cells express the
CCR5 coreceptor, whereas a
small fraction of CD4+ T cells in
the bloodstream do so.
HIV seeks out and destroys CCR5
expressing CD4+ cells during
acute infection. A vigorous
immune response eventually
controls the infection and initiates
the clinically latent phase.
However, CD4+ T cells in mucosal tissues remain depleted throughout the
infection, although enough remain to initially ward off life-threatening
infections (Source: The World Health Organization).
Estimated per act risk for acquisition
of HIV by exposure route.
Exposure Route
Estimated infections
per 10,000 exposures
to an infected source
Blood Transfusion 9,000
Childbirth 2,500
Needle-sharing injection drug use 67
Percutaneous needle stick 30
Receptive anal intercourse* 50
Insertive anal intercourse* 6.5
Receptive penile-vaginal intercourse* 10
Insertive penile-vaginal intercourse* 5
Receptive oral intercourse*§ 1
Insertive oral intercourse*§ 0.5
* assuming no condom use
§ source refers to oral intercourse
performed on a man
11
11
Continuous HIV replication results in a state of generalized immune
activation persisting throughout the chronic phase. Immune activation,
which is reflected by the increased activation state of immune cells and
release of proinflammatory cytokines, results from the activity of several
HIV gene products and the immune response to ongoing HIV replication.
Another cause is the breakdown of the immune surveillance system of the
mucosal barrier caused by the depletion of mucosal CD4+ T cells during the
acute phase of disease.
This results in the systemic exposure of the immune system to microbial
components of the gut’s normal flora, which in a healthy person is kept in
check by the mucosal immune system. The activation and proliferation of T
cells that results from immune activation provides fresh targets for HIV
infection. However, direct killing by HIV alone cannot account for the
observed depletion of CD4+ T cells since only 0.01-0.10% of CD4+ T cells
in the blood are infected. A major cause of CD4+ T cell loss appears to
result from their heightened susceptibility to apoptosis when the immune
system remains activated. Although new T cells are continuously produced
by the thymus to replace the ones lost, the regenerative capacity of the
thymus is slowly destroyed by direct infection of its thymocytes by HIV.
Eventually, the minimal number of CD4+ T cells necessary to maintain a
sufficient immune response is lost, leading to AIDS (Source: The World
Health Organization).
3. Epidemiology
Estimated prevalence of HIV among young adults (15-49) per country at the end of 2005
The AIDS pandemic can also be seen as several epidemics of separate
subtypes; the major factors in its spread are sexual transmission and vertical
12
12
transmission from mother to child at birth and through breast milk. Despite
recent, improved access to antiretroviral treatment and care in many regions
of the world, the AIDS pandemic claimed an estimated 2.1 million (range
1.9–2.4 million) lives in 2007 of which an estimated 330,000 were children
under 15 years. Globally, an estimated 33.2 million people lived with HIV in
2007, including 2.5 million children. An estimated 2.5 million (range 1.8–
4.1 million) people were newly infected in 2007, including 420,000 children
(Source: The World Health Organization).
Sub-Saharan Africa remains by far the worst affected region. In 2007 it
contained an estimated 68% of all people living with AIDS and 76% of all
AIDS deaths, with 1.7 million new infections bringing the number of people
living with HIV to 22.5 million, and with 11.4 million AIDS orphans living
in the region. Unlike other regions, most people living with HIV in sub-
Saharan Africa in 2007 (61%) were women. Adult prevalence in 2007 was
an estimated 5.0%, and AIDS continued to be the single largest cause of
mortality in this region. South Africa has the largest population of HIV
patients in the world, followed by Nigeria and India. South & South East
Asia are second worst affected; in 2007 this region contained an estimated
18% of all people living with AIDS, and an estimated 300,000 deaths from
AIDS. India has an estimated 2.5 million infections and an estimated adult
prevalence of 0.36%. Life expectancy has fallen dramatically in the worstaffected
countries; for example, in 2006 it was estimated that it had dropped
from 65 to 35 years in Botswana (Source: The World Health Organization).
Changes in life expectancy in some hard-hit African countries. Botswana
Zimbabwe Kenya South Africa Uganda
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material
may be transmitted or reproduced in any form, or by any means, mechanical or
electronic without written permission of Aspira Continuing Education.
1. Differentiate between HIV and AIDS
2. Identify causes
3. Learn epidemiology
4. Learn the historical framework related to the development of
HIV/AIDS
5. Become familiar with the impact HIV/AIDS on culture
6. Identify and recognize common stigmas associated with HIV/AIDS
7. Increase familiarity with the relationship between HIV/AIDS and
mental health
8. Increase familiarity with the relationship between HIV/AIDS and
substance abuse
9. Develop the ability to identify the characteristics and method of
assessment and treatment of people who live with HIV/AIDS.
Table of Contents:
1. Definitions
2. Causes
3. Epidemiology
2
4. History
5. Stigma
6. HIV/AIDS and Mental Health
7. HIV/AIDS and Substance Abuse
8. Cognitive Disorders
9. Summary
10. References
1. Definitions
Human immunodeficiency virus (HIV) is a lentivirus (a member of the
retrovirus family) that can lead to acquired immunodeficiency syndrome
(AIDS), a condition in humans in which the immune system begins to fail,
leading to life-threatening opportunistic infections. Previous names for the
virus include human T-lymphotropic virus-III (HTLV-III),
lymphadenopathy-associated virus (LAV), and AIDS-associated retrovirus
(ARV). Infection with HIV occurs by the transfer of blood, semen, vaginal
fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present
as both free virus particles and virus within infected immune cells. The four
major routes of transmission are unprotected sexual intercourse,
contaminated needles, breast milk, and transmission from an infected mother
to her baby at birth (Vertical transmission). Screening of blood products for
HIV has largely eliminated transmission through blood transfusions or
infected blood products in the developed world (Appay V, Sauce D, January
2008. "Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
HIV infection in humans is now pandemic. As
of January 2006, the Joint United Nations
Programme on HIV/AIDS (UNAIDS) and the
World Health Organization (WHO) estimate that
AIDS has killed more than 25 million people
since it was first recognized on December 1,
1981. It is estimated that about 0.6 percent of the
world's population is infected with HIV. In
2005 alone, AIDS claimed an estimated 2.4–3.3
million lives, of which more than 570,000 were
children. A third of these deaths are occurring in
sub-Saharan Africa, retarding economic growth
and increasing poverty. According to current
estimates, HIV is set to infect 90 million people
in Africa, resulting in a minimum estimate of 18 million orphans.
Antiretroviral treatment reduces both the mortality and the morbidity of HIV
infection, but routine access to antiretroviral medication is not available in
all countries. HIV primarily infects vital cells in the human immune system
such as helper T cells (specifically CD4+ T cells), macrophages, and
Human
immunodeficiency virus
Scanning electron micrograph
of HIV-1 (in green) budding
from cultured lymphocyte.
Multiple round bumps on cell
surface represent sites of
assembly and budding of
virions.
dendritic cells. HIV infection leads to low levels of CD4+ T cells through
three main mechanisms: firstly, direct viral killing of infected cells;
secondly, increased rates of apoptosis in infected cells; and thirdly, killing of
infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected
cells. When CD4+ T cell numbers decline below a critical level, cellmediated
immunity is lost, and the body becomes progressively more
susceptible to opportunistic infections (Appay V, Sauce D, January 2008.
"Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Eventually most HIV-infected individuals develop AIDS (Acquired
Immunodeficiency Syndrome). These individuals mostly die from
opportunistic infections or malignancies associated with the progressive
failure of the immune system. Without treatment, about 9 out of every 10
persons with HIV will progress to AIDS after 10-15 years. Many people
deteriorate much sooner. Treatment with anti-retrovirals increases the life
expectancy of people infected with HIV. Even after HIV has progressed to
diagnosable AIDS, the average survival time with antiretroviral therapy (as
of 2005) is estimated to be more than 5 years. Without antiretroviral therapy,
death normally occurs within a year. It is hoped that current and future
treatments may allow HIV-infected individuals to achieve a life expectancy
approaching that of the general public (Appay V, Sauce D, January 2008.
"Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Acquired immune deficiency syndrome or acquired immunodeficiency
syndrome (AIDS) is a set of symptoms and infections resulting from the
damage to the human immune system caused by the human
immunodeficiency virus (HIV). This condition progressively reduces the
effectiveness of the immune system and leaves individuals susceptible to
opportunistic infections and tumors. HIV is transmitted through direct
contact of a mucous membrane or the bloodstream with a bodily fluid
containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and
breast milk (Appay V, Sauce D (January 2008). "Immune activation and
inflammation in HIV-1 infection: causes and consequences". J. Pathol.)
This transmission can involve anal, vaginal or oral sex, blood transfusion,
contaminated hypodermic needles, exchange between mother and baby
during pregnancy, childbirth, or breastfeeding, or other exposure to one of
the above bodily fluids (Appay V, Sauce D, January 2008. "Immune
activation and inflammation in HIV-1 infection: causes and consequences".
J. Pathol).
AIDS is now a pandemic. In 2007, an estimated 33.2 million people lived
with the disease worldwide, and it killed an estimated 2.1 million people,
including 330,000 children. Over three-quarters of these deaths occurred in
sub-Saharan Africa, retarding economic growth and destroying human
capital. Genetic research indicates that HIV originated in west-central
Africa during the late nineteenth or early twentieth century. AIDS was first
recognized by the U.S. Centers for Disease Control and Prevention in 1981
and its cause, HIV, identified in the early 1980s (Appay V, Sauce D, January
2008. "Immune activation and inflammation in HIV-1 infection: causes and
consequences". J. Pathol).
Although treatments for AIDS and HIV can slow the course of the disease,
there is currently no vaccine or cure. Antiretroviral treatment reduces both
the mortality and the morbidity of HIV infection, but these drugs are
expensive and routine access to antiretroviral medication is not available in
all countries. Due to the difficulty in treating HIV infection, preventing
infection is a key aim in controlling the AIDS epidemic, with health
organizations promoting safe sex and needle-exchange programs in attempts
to slow the spread of the virus (Appay V, Sauce D, January 2008. "Immune
activation and inflammation in HIV-1 infection: causes and consequences".
J. Pathol).
2. Causes
AIDS is the most severe acceleration of infection with HIV. HIV is a
retrovirus that primarily infects vital organs of the human immune system
such as CD4+ T cells (a subset of T cells), macrophages and dendritic cells.
It directly and indirectly destroys CD4+ T cells. Once HIV has killed so
many CD4+ T cells that there are fewer than 200 of these cells per microliter
(µL) of blood, cellular immunity is lost. Acute HIV infection progresses
over time to clinical latent HIV infection and then to early symptomatic HIV
infection and later to AIDS, which is identified either on the basis of the
amount of CD4+ T cells remaining in the blood, and/or the presence of
certain infections (Appay V, Sauce D, January 2008. "Immune activation
and inflammation in HIV-1 infection: causes and consequences". J. Pathol).
Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte.
In the absence of antiretroviral therapy, the median time of progression from
HIV infection to AIDS is nine to ten years, and the median survival time
after developing AIDS is only 9.2 months. However, the rate of clinical
disease progression varies widely between individuals, from two weeks up
to 20 years. Many factors affect the rate of progression. These include
factors that influence the body's ability to defend against HIV such as the
infected person's general immune function. Older people have weaker
immune systems, and therefore have a greater risk of rapid disease
progression than younger people. Poor access to health care and the
existence of coexisting infections such as tuberculosis also may predispose
people to faster disease progression. The infected person's genetic
inheritance plays an important role and some people are resistant to certain
strains of HIV. An example of this is people with the homozygous CCR5-
Δ32 variation are resistant to infection with certain strains of HIV. HIV is
genetically variable and exists as different strains, which cause different
rates of clinical disease progression (Mastro TD, de Vincenzi I, 1996.
Probabilities of sexual HIV-1 transmission).
Sexual transmission
Sexual transmission occurs with the contact between sexual secretions of
one person with the rectal, genital or oral mucous membranes of another.
Unprotected receptive sexual acts are riskier than unprotected insertive
sexual acts, and the risk for transmitting HIV through unprotected anal
intercourse is greater than the risk from vaginal intercourse or oral sex.
However, oral sex is not entirely safe, as HIV can be transmitted through
both insertive and receptive oral sex. Sexual assault greatly increases the risk
of HIV transmission as protection is rarely employed and physical trauma to
the vagina occurs frequently, facilitating the transmission of HIV. Other
sexually transmitted infections (STI) increase the risk of HIV transmission
and infection, because they cause the disruption of the normal epithelial
barrier by genital ulceration and/or microulceration; and by accumulation of
pools of HIV-susceptible or HIV-infected cells (lymphocytes and
macrophages) in semen and vaginal secretions. Epidemiological studies
from sub-Saharan Africa, Europe and North America suggest that genital
ulcers, such as those caused by syphilis and/or chancroid, increase the risk of
becoming infected with HIV by about fourfold. There is also a significant
although lesser increase in risk from STIs such as gonorrhea, Chlamydial
infection and trichomoniasis, which all cause local accumulations of
lymphocytes and macrophages (Mastro TD, de Vincenzi I, 1996.
Probabilities of sexual HIV-1 transmission).
Transmission of HIV depends on the infectiousness of the index case and the
susceptibility of the uninfected partner. Infectivity seems to vary during the
course of illness and is not constant between individuals. An undetectable
plasma viral load does not necessarily indicate a low viral load in the
seminal liquid or genital secretions. However, each 10-fold increase in the
level of HIV in the blood is associated with an 81% increased rate of HIV
transmission. Women are more susceptible to HIV-1 infection due to
hormonal changes, vaginal microbial ecology and physiology, and a higher
prevalence of sexually transmitted diseases. People who have been infected
with one strain of HIV can still be infected later on in their lives by other,
more virulent strains. Infection is unlikely in a single encounter. High rates
of infection have been linked to a pattern of overlapping long-term romantic
relationships. This allows the virus to quickly spread to multiple partners
who in turn infect their partners. A pattern of serial monogamy or occasional
casual encounters is associated with lower rates of infection. HIV spreads
readily through heterosexual sex in Africa, but less so elsewhere. One
possibility being researched is that schistosomiasis, which affects up to 50
per cent of women in parts of Africa, damages the lining of the vagina
(Mastro TD, de Vincenzi I, 1996. "Probabilities of sexual HIV-1
transmission).
Exposure to blood-borne pathogens
(CDC poster from 1989 highlighting the threat of AIDS associated with drug use)
This transmission route is particularly relevant to intravenous drug users,
hemophiliacs and recipients of blood transfusions and blood products.
Sharing and reusing syringes contaminated with HIV-infected blood
represents a major risk for infection with HIV. Needle sharing is the cause
of one third of all new HIV-infections in North America, China, and Eastern
Europe. The risk of being infected with HIV from a single prick with a
needle that has been used on an HIV-infected person is thought to be about 1
in 150. Post-exposure prophylaxis with anti-HIV drugs can further reduce
this risk. This route can also affect people who give and receive tattoos and
piercings. Universal precautions are frequently not followed in both sub-
Saharan Africa and much of Asia because of both a shortage of supplies and
inadequate training. The WHO estimates that approximately 2.5% of all HIV
infections in sub-Saharan Africa are transmitted through unsafe healthcare
injections. Because of this, the United Nations General Assembly has urged
the nations of the world to implement precautions to prevent HIV
transmission by health workers. The risk of transmitting HIV to blood
transfusion recipients is extremely low in developed countries where
improved donor selection and HIV screening is performed. However,
according to the WHO, the overwhelming majority of the world's population
does not have access to safe blood and between 5% and 10% of the world's
9
9
HIV infections come from transfusion of infected blood and blood products
(Source: The World Health Organization).
Perinatal transmission
The transmission of the virus from the mother to the child can occur in utero
during the last weeks of pregnancy and at childbirth. In the absence of
treatment, the transmission rate between a mother and her child during
pregnancy, labor and delivery is 25%. However, when the mother takes
antiretroviral therapy and gives birth by caesarean section, the rate of
transmission is just 1%. The risk of infection is influenced by the viral load
of the mother at birth, with the higher the viral load, the higher the risk.
Breastfeeding also increases the risk of transmission by about 4 % (Source:
The World Health Organization).
Misconceptions
A number of misconceptions have arisen surrounding HIV/AIDS. Three of
the most common are that AIDS can spread through casual contact, that
sexual intercourse with a virgin will cure AIDS, and that HIV can infect
only homosexual men and drug users. Other misconceptions are that any act
of anal intercourse between gay men can lead to AIDS infection, and that
open discussion of homosexuality and HIV in schools will lead to increased
rates of homosexuality and AIDS (Source: The World Health
Organization).
Pathophysiology
The pathophysiology of AIDS is complex, as is the case with all syndromes.
Ultimately, HIV causes AIDS by depleting CD4+ T helper lymphocytes.
This weakens the immune system and allows opportunistic infections. T
lymphocytes are essential to the immune response and without them, the
body cannot fight infections or kill cancerous cells. The mechanism of CD4+
T cell depletion differs in the acute and chronic phases.
10
10
During the acute phase, HIVinduced
cell lysis and killing of
infected cells by cytotoxic T cells
accounts for CD4+ T cell
depletion, although apoptosis may
also be a factor. During the
chronic phase, the consequences
of generalized immune activation
coupled with the gradual loss of
the ability of the immune system
to generate new T cells appear to
account for the slow decline in
CD4+ T cell numbers.
Although the symptoms of
immune deficiency characteristic
of AIDS do not appear for years
after a person is infected, the bulk
of CD4+ T cell loss occurs during
the first weeks of infection,
especially in the intestinal
mucosa, which harbors the
majority of the lymphocytes
found in the body. The reason for
the preferential loss of mucosal
CD4+ T cells is that a majority of
mucosal CD4+ T cells express the
CCR5 coreceptor, whereas a
small fraction of CD4+ T cells in
the bloodstream do so.
HIV seeks out and destroys CCR5
expressing CD4+ cells during
acute infection. A vigorous
immune response eventually
controls the infection and initiates
the clinically latent phase.
However, CD4+ T cells in mucosal tissues remain depleted throughout the
infection, although enough remain to initially ward off life-threatening
infections (Source: The World Health Organization).
Estimated per act risk for acquisition
of HIV by exposure route.
Exposure Route
Estimated infections
per 10,000 exposures
to an infected source
Blood Transfusion 9,000
Childbirth 2,500
Needle-sharing injection drug use 67
Percutaneous needle stick 30
Receptive anal intercourse* 50
Insertive anal intercourse* 6.5
Receptive penile-vaginal intercourse* 10
Insertive penile-vaginal intercourse* 5
Receptive oral intercourse*§ 1
Insertive oral intercourse*§ 0.5
* assuming no condom use
§ source refers to oral intercourse
performed on a man
11
11
Continuous HIV replication results in a state of generalized immune
activation persisting throughout the chronic phase. Immune activation,
which is reflected by the increased activation state of immune cells and
release of proinflammatory cytokines, results from the activity of several
HIV gene products and the immune response to ongoing HIV replication.
Another cause is the breakdown of the immune surveillance system of the
mucosal barrier caused by the depletion of mucosal CD4+ T cells during the
acute phase of disease.
This results in the systemic exposure of the immune system to microbial
components of the gut’s normal flora, which in a healthy person is kept in
check by the mucosal immune system. The activation and proliferation of T
cells that results from immune activation provides fresh targets for HIV
infection. However, direct killing by HIV alone cannot account for the
observed depletion of CD4+ T cells since only 0.01-0.10% of CD4+ T cells
in the blood are infected. A major cause of CD4+ T cell loss appears to
result from their heightened susceptibility to apoptosis when the immune
system remains activated. Although new T cells are continuously produced
by the thymus to replace the ones lost, the regenerative capacity of the
thymus is slowly destroyed by direct infection of its thymocytes by HIV.
Eventually, the minimal number of CD4+ T cells necessary to maintain a
sufficient immune response is lost, leading to AIDS (Source: The World
Health Organization).
3. Epidemiology
Estimated prevalence of HIV among young adults (15-49) per country at the end of 2005
The AIDS pandemic can also be seen as several epidemics of separate
subtypes; the major factors in its spread are sexual transmission and vertical
12
12
transmission from mother to child at birth and through breast milk. Despite
recent, improved access to antiretroviral treatment and care in many regions
of the world, the AIDS pandemic claimed an estimated 2.1 million (range
1.9–2.4 million) lives in 2007 of which an estimated 330,000 were children
under 15 years. Globally, an estimated 33.2 million people lived with HIV in
2007, including 2.5 million children. An estimated 2.5 million (range 1.8–
4.1 million) people were newly infected in 2007, including 420,000 children
(Source: The World Health Organization).
Sub-Saharan Africa remains by far the worst affected region. In 2007 it
contained an estimated 68% of all people living with AIDS and 76% of all
AIDS deaths, with 1.7 million new infections bringing the number of people
living with HIV to 22.5 million, and with 11.4 million AIDS orphans living
in the region. Unlike other regions, most people living with HIV in sub-
Saharan Africa in 2007 (61%) were women. Adult prevalence in 2007 was
an estimated 5.0%, and AIDS continued to be the single largest cause of
mortality in this region. South Africa has the largest population of HIV
patients in the world, followed by Nigeria and India. South & South East
Asia are second worst affected; in 2007 this region contained an estimated
18% of all people living with AIDS, and an estimated 300,000 deaths from
AIDS. India has an estimated 2.5 million infections and an estimated adult
prevalence of 0.36%. Life expectancy has fallen dramatically in the worstaffected
countries; for example, in 2006 it was estimated that it had dropped
from 65 to 35 years in Botswana (Source: The World Health Organization).
Changes in life expectancy in some hard-hit African countries. Botswana
Zimbabwe Kenya South Africa Uganda
January 17, 2010
Substance Abuse Dependency CEU MFT LMFT
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.
1. Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes. 2. Define substance abuse and identify its efftects. 3. Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency. 4. Apply current theories of the etiology of substance abuse. 5. Recognize the role of persons and systems that support or compound the abuse. 6. Become familiar with the major treatment approaches to alcoholism and chemical dependency. 7. Learn the national legal aspects of substance abuse. 8. Obtain knowledge of certain populations at risk with regard to substance abuse. 9. Access community resources offering assessment, treatment and follow-up for the abuser and family. 10. Learn the process of referring affected persons.
Table of Contents:
1. Definitions 2. History 3. DSM Criteria 4. Types of Substance Abuse 5. Prescription Drug Addiction and Dependence 6. Demographic Characteristics 7. Substance Abuse Treatment and Outcomes 8. References
1. DEFINITIONS
Substance abuse is defined as “the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. It is characterized by a pattern of continued pathological use of a medication, non-medically indicated substance, drug or toxin, that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. Some controversy exists regarding the precise distinctions between substance abuse and substance dependence. However, the current clinical standard distinguishes between them by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use. Substance abuse may lead to addiction or substance dependence. Dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse. However, abuse frequently occurs without dependence. Dependence involves added physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.”
2. HISTORY
Throughout history, in fact for thousands of years, substance abuse has existed. Early Egyptians drank wine while narcotics were used dating back to 4000 B.C. Medicinal use of marijuana has been dated back to 2737 B.C. in China. During the 19th century, the active substances in drugs began to be extracted. At that time, substances including morphine, laudanum, and cocaine were unregulated and prescribed by physicians for a variety of illnesses. During the American Civil War, morphine was commonly used, and wounded veterans returned home with morphine kits and hypodermic needles. Opium dens grew and by the early 1900s there were an estimated 250,000 addicts in the United States (Office of Applied Studies, Substance Abuse and Mental Health Services Administration).
1. Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes. 2. Define substance abuse and identify its efftects. 3. Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency. 4. Apply current theories of the etiology of substance abuse. 5. Recognize the role of persons and systems that support or compound the abuse. 6. Become familiar with the major treatment approaches to alcoholism and chemical dependency. 7. Learn the national legal aspects of substance abuse. 8. Obtain knowledge of certain populations at risk with regard to substance abuse. 9. Access community resources offering assessment, treatment and follow-up for the abuser and family. 10. Learn the process of referring affected persons.
Table of Contents:
1. Definitions 2. History 3. DSM Criteria 4. Types of Substance Abuse 5. Prescription Drug Addiction and Dependence 6. Demographic Characteristics 7. Substance Abuse Treatment and Outcomes 8. References
1. DEFINITIONS
Substance abuse is defined as “the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. It is characterized by a pattern of continued pathological use of a medication, non-medically indicated substance, drug or toxin, that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. Some controversy exists regarding the precise distinctions between substance abuse and substance dependence. However, the current clinical standard distinguishes between them by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use. Substance abuse may lead to addiction or substance dependence. Dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse. However, abuse frequently occurs without dependence. Dependence involves added physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.”
2. HISTORY
Throughout history, in fact for thousands of years, substance abuse has existed. Early Egyptians drank wine while narcotics were used dating back to 4000 B.C. Medicinal use of marijuana has been dated back to 2737 B.C. in China. During the 19th century, the active substances in drugs began to be extracted. At that time, substances including morphine, laudanum, and cocaine were unregulated and prescribed by physicians for a variety of illnesses. During the American Civil War, morphine was commonly used, and wounded veterans returned home with morphine kits and hypodermic needles. Opium dens grew and by the early 1900s there were an estimated 250,000 addicts in the United States (Office of Applied Studies, Substance Abuse and Mental Health Services Administration).
January 16, 2010
Aging and Long Term Care CEUs
Copyright 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.
1. Define aging and long term care 2. Become familiar with relevant demographic information. 3. Obtain information that includes but is not limited to, the biological, social, and psychological aspects of aging. 4. Learn the psychological impact of aging 5. Describe the relationship between aging and culture 6. Distinguish between long term and alternative types of care 7. Identify and access relevant resources Table of Contents: 1. Definitions 2. Demographic Information 3. Biological Aging 4. Aging and Culture 5. Long Term Care 6. Psychological Considerations 7. Elder and Dependent Adult Abuse Reporting 8. Resources 9. References
1. Definitions
Aging is defined as “the accumulation of changes in an organism over time.” Aging is also a multidimensional process of physical, psychological, and social change (Masoro E.J. & Austad S.N..eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006). Some dimensions of aging grow and expand over time, while others decline. For example, although reaction time may decrease with age, knowledge of world events and wisdom may increase. Research shows that even late in life potential exists for physical, mental, and social growth and development (Strawbridge, W.J., Wallhagen, M.I. & Cohen, R.D., 2002. Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist). Aging is an important part of all human societies which not only reflects the biological changes that occur, but also the cultural and societal conventions (Masoro E.J. & Austad S.N.. eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006).
2. Demographic Information
The number of Americans age 55 and older will almost double between now and the year 2030. This number will grow from 60 million today (21 percent of the total US population) to 107.6 million (31 percent of the population) as the Baby Boomers reach retirement age. During that same period of time, the number of Americans over 65 will more than double, from 34.8 million in 2000 (12 percent of the population) to 70.3 million in 2030 (20 percent of the total population). The next generation of retirees will be the healthiest, longest lived, best educated, and most affluent in history. Americans reaching age 65 today have an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males).
The likelihood that an American who reaches the age of 65 will survive to the age of 90 has nearly doubled over the past 40 years from just 14 percent of 65-year-olds in 1960 to 25 percent at present. By 2050, 40 percent of 65-year-olds are likely to reach age 90 (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes, Eds. Successful aging: Perspectives from the Behavioural Sciences). Highest level of education achieved is increasing in the older population. Although less than one-third of today’s adults aged 70-74 have at least some college education that percentage will increase to more than 50 percent by the year 2015. Currently, older Americans possess more financial resources compared to previous generations. Households headed by persons age 65 and older reported a median income in 2000 of $32,854 ($33,467 for Caucasians, $27,952 for African-Americans, and $24,330 for Hispanics).
While one of every eight (12.1 percent) households headed by someone age 65 or older had incomes less than $15,000, nearly half (49.2 percent) had annual incomes of $35,000 or more, and nearly three in ten households (29.8 percent) had incomes greater than $50,000 per year (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences).
Approximately fifty percent of Americans age 55 and over volunteered at least once in 2002. Even among those aged 75 and older, 43 percent had volunteered at some point in the previous year. Older volunteers devoted the most time to community activities amounting to almost double the national median for all ages. Compared with the U.S. median commitment of 52 volunteer hours annually, those 65 and over contributed 96 hours per year. (U.S. Department of Labor's Bureau of Labor Statistics, Volunteering in the United States, December 2002). It is Older Adults as Volunteers Age 55 to 64 Age 65 to 74 Age 75+ % of age group who volunteer 50.3 % 46.6 % 43.0 % total number of volunteers 11.9 million 8.5 million 7.1 million Avg weekly hours/volunteer 3.3 hours 3.6 hours 3.1 hours Total time volunteered annually 4.8 billion hours 1.6 billion hours 1.1 billion hours estimated that the number of older volunteers would increase significantly if more were asked to volunteer or were offered an incentive. Older Americans now view retirement as an increasingly active, engaged phase of life that includes work and public service. Factors in the Decision to Work in Retirement (%)* Pre-retirees who plan Working to work in retirement retirees Total Desire to stay mentally active 87 68 83 Desire to stay physically active 85 61 80 Desire to remain productive or useful 77 73 76 Desire to do something fun or enjoyable 71 49 66 Need health benefits 66 20 56 Desire to help other people 59 44 56 Desire to be around people 58 47 55 Need the money 54 51 53 Desire to learn new things 50 37 48 Desire to pursue a dream 32 20 29 (Source: AARP, Staying Ahead of the Curve 2003) According to a 2002 survey conducted for Civic Ventures, 59 percent of older Americans view retirement as “a time to be active and involved, to start new activities, and to set new goals.” Just 24 percent see retirement as “a time to enjoy leisure activities and take a much deserved rest.” Retirees who intend to work during their retirement identify the desire to stay active and productive, rather than economic necessity, as the primary reason. More than half of the respondents (56 percent) say civic engagement will be at least a fairly important part of retirement (Peter D. Hart Research Associates, “The New Face of Retirement: An Ongoing Survey of American Attitudes on Aging,” San Francisco: Civic Ventures, 2002).
A 2003 survey conducted for AARP found that many Americans between the ages of 50 and 70 plan to work far into what has traditionally been viewed as their "retirement years": • Nearly half of all pre-retirees (45 percent) expect to continue working into their 70s or later. Of this group, 27 percent said they would work until they were in their 70s, and 18 percent said “80 or older,” “never stop working,” or “as long as they are able to work.” • The most common reasons given by pre-retirees for wanting to continue working in retirement were the desire to stay “mentally active” (87 percent) or “physically active” (85 percent), and the desire “to remain productive or useful” (77 percent). Slightly more than half of the pre-retirees (54 percent) indicated that their motivation was based on "a need for money.” (S. Kathi Brown, “Staying Ahead of the Curve 2003: The AARP Working in Retirement Study,” Washington, DC: AARP, 2003). • The result of these demographic trends is the emergence of a new life-stage between adulthood and true old age – which has been called the “third age” or “midcourse” or “my time.” (Source: AARP, Staying Ahead of the Curve 2003) “The third age is no longer a brief intermezzo between midlife and drastic decline… Instead, it has the potential to become the best stage of all, an age of liberation when individuals combine newfound freedoms with prolonged health and the chance to make some of their most important contributions to life.” Mark Freedman, founder of Civic Ventures, author of PrimeTime: How Baby Boomers Will Revolutionize Retirement and Transform America. “Midcourse connotes the period in which individuals begin to think about, plan for, and actually disengage from their primary career occupations and the raising of children; launch second or third careers; develop new identities and new ways to be productively engaged; establish new patterns of relating to spouses, children, siblings, parents, friends; leave some existing relationships and begin new ones…. The fact that most retirees say that they retired ‘to do other things’ suggests that midcoursers are retiring to move to something else, not simply from boring or demanding jobs.” Phyllis Moen, McKnight Presidential Chair, Sociology, University of Minnesota. “Midcourse: Navigating Retirement and a New Life Stage.” Jeylan Mortimer and Michael J. Shanahan, eds., Handbook of the Life Course. New York: Kluwer Publishers, 2003. “Something huge is happening here… The emergence of an older, more vigorous population is the most significant story of our times.”, Abigail Trafford, Washington Post health columnist and author, My Time: Making the Most of the Rest of Your Life.
1. Define aging and long term care 2. Become familiar with relevant demographic information. 3. Obtain information that includes but is not limited to, the biological, social, and psychological aspects of aging. 4. Learn the psychological impact of aging 5. Describe the relationship between aging and culture 6. Distinguish between long term and alternative types of care 7. Identify and access relevant resources Table of Contents: 1. Definitions 2. Demographic Information 3. Biological Aging 4. Aging and Culture 5. Long Term Care 6. Psychological Considerations 7. Elder and Dependent Adult Abuse Reporting 8. Resources 9. References
1. Definitions
Aging is defined as “the accumulation of changes in an organism over time.” Aging is also a multidimensional process of physical, psychological, and social change (Masoro E.J. & Austad S.N..eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006). Some dimensions of aging grow and expand over time, while others decline. For example, although reaction time may decrease with age, knowledge of world events and wisdom may increase. Research shows that even late in life potential exists for physical, mental, and social growth and development (Strawbridge, W.J., Wallhagen, M.I. & Cohen, R.D., 2002. Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist). Aging is an important part of all human societies which not only reflects the biological changes that occur, but also the cultural and societal conventions (Masoro E.J. & Austad S.N.. eds: Handbook of the Biology of Aging, Sixth Edition. Academic Press. San Diego, CA, USA, 2006).
2. Demographic Information
The number of Americans age 55 and older will almost double between now and the year 2030. This number will grow from 60 million today (21 percent of the total US population) to 107.6 million (31 percent of the population) as the Baby Boomers reach retirement age. During that same period of time, the number of Americans over 65 will more than double, from 34.8 million in 2000 (12 percent of the population) to 70.3 million in 2030 (20 percent of the total population). The next generation of retirees will be the healthiest, longest lived, best educated, and most affluent in history. Americans reaching age 65 today have an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males).
The likelihood that an American who reaches the age of 65 will survive to the age of 90 has nearly doubled over the past 40 years from just 14 percent of 65-year-olds in 1960 to 25 percent at present. By 2050, 40 percent of 65-year-olds are likely to reach age 90 (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes, Eds. Successful aging: Perspectives from the Behavioural Sciences). Highest level of education achieved is increasing in the older population. Although less than one-third of today’s adults aged 70-74 have at least some college education that percentage will increase to more than 50 percent by the year 2015. Currently, older Americans possess more financial resources compared to previous generations. Households headed by persons age 65 and older reported a median income in 2000 of $32,854 ($33,467 for Caucasians, $27,952 for African-Americans, and $24,330 for Hispanics).
While one of every eight (12.1 percent) households headed by someone age 65 or older had incomes less than $15,000, nearly half (49.2 percent) had annual incomes of $35,000 or more, and nearly three in ten households (29.8 percent) had incomes greater than $50,000 per year (Fentleman, D.L., Smith, J. & Peterson, J., 1990. Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes Eds. Successful aging: Perspectives from the Behavioural Sciences).
Approximately fifty percent of Americans age 55 and over volunteered at least once in 2002. Even among those aged 75 and older, 43 percent had volunteered at some point in the previous year. Older volunteers devoted the most time to community activities amounting to almost double the national median for all ages. Compared with the U.S. median commitment of 52 volunteer hours annually, those 65 and over contributed 96 hours per year. (U.S. Department of Labor's Bureau of Labor Statistics, Volunteering in the United States, December 2002). It is Older Adults as Volunteers Age 55 to 64 Age 65 to 74 Age 75+ % of age group who volunteer 50.3 % 46.6 % 43.0 % total number of volunteers 11.9 million 8.5 million 7.1 million Avg weekly hours/volunteer 3.3 hours 3.6 hours 3.1 hours Total time volunteered annually 4.8 billion hours 1.6 billion hours 1.1 billion hours estimated that the number of older volunteers would increase significantly if more were asked to volunteer or were offered an incentive. Older Americans now view retirement as an increasingly active, engaged phase of life that includes work and public service. Factors in the Decision to Work in Retirement (%)* Pre-retirees who plan Working to work in retirement retirees Total Desire to stay mentally active 87 68 83 Desire to stay physically active 85 61 80 Desire to remain productive or useful 77 73 76 Desire to do something fun or enjoyable 71 49 66 Need health benefits 66 20 56 Desire to help other people 59 44 56 Desire to be around people 58 47 55 Need the money 54 51 53 Desire to learn new things 50 37 48 Desire to pursue a dream 32 20 29 (Source: AARP, Staying Ahead of the Curve 2003) According to a 2002 survey conducted for Civic Ventures, 59 percent of older Americans view retirement as “a time to be active and involved, to start new activities, and to set new goals.” Just 24 percent see retirement as “a time to enjoy leisure activities and take a much deserved rest.” Retirees who intend to work during their retirement identify the desire to stay active and productive, rather than economic necessity, as the primary reason. More than half of the respondents (56 percent) say civic engagement will be at least a fairly important part of retirement (Peter D. Hart Research Associates, “The New Face of Retirement: An Ongoing Survey of American Attitudes on Aging,” San Francisco: Civic Ventures, 2002).
A 2003 survey conducted for AARP found that many Americans between the ages of 50 and 70 plan to work far into what has traditionally been viewed as their "retirement years": • Nearly half of all pre-retirees (45 percent) expect to continue working into their 70s or later. Of this group, 27 percent said they would work until they were in their 70s, and 18 percent said “80 or older,” “never stop working,” or “as long as they are able to work.” • The most common reasons given by pre-retirees for wanting to continue working in retirement were the desire to stay “mentally active” (87 percent) or “physically active” (85 percent), and the desire “to remain productive or useful” (77 percent). Slightly more than half of the pre-retirees (54 percent) indicated that their motivation was based on "a need for money.” (S. Kathi Brown, “Staying Ahead of the Curve 2003: The AARP Working in Retirement Study,” Washington, DC: AARP, 2003). • The result of these demographic trends is the emergence of a new life-stage between adulthood and true old age – which has been called the “third age” or “midcourse” or “my time.” (Source: AARP, Staying Ahead of the Curve 2003) “The third age is no longer a brief intermezzo between midlife and drastic decline… Instead, it has the potential to become the best stage of all, an age of liberation when individuals combine newfound freedoms with prolonged health and the chance to make some of their most important contributions to life.” Mark Freedman, founder of Civic Ventures, author of PrimeTime: How Baby Boomers Will Revolutionize Retirement and Transform America. “Midcourse connotes the period in which individuals begin to think about, plan for, and actually disengage from their primary career occupations and the raising of children; launch second or third careers; develop new identities and new ways to be productively engaged; establish new patterns of relating to spouses, children, siblings, parents, friends; leave some existing relationships and begin new ones…. The fact that most retirees say that they retired ‘to do other things’ suggests that midcoursers are retiring to move to something else, not simply from boring or demanding jobs.” Phyllis Moen, McKnight Presidential Chair, Sociology, University of Minnesota. “Midcourse: Navigating Retirement and a New Life Stage.” Jeylan Mortimer and Michael J. Shanahan, eds., Handbook of the Life Course. New York: Kluwer Publishers, 2003. “Something huge is happening here… The emergence of an older, more vigorous population is the most significant story of our times.”, Abigail Trafford, Washington Post health columnist and author, My Time: Making the Most of the Rest of Your Life.
January 10, 2010
Tips for Easing Money Worries
These tips can help create a sense of
calm and well-being.
1. Give yourself a break. It takes
time to get used to diminished
circumstances. Accept your
feelings and talk to yourself in
soothing ways.
2. Focus on the good. When fear arises,
remind yourself of the stability in
your life: your savings, spouse’s
income, your own good health.
3. Exercise. Physical activity can
raise the mood and discharge
anxious energy.
4. Try yoga and meditation. Both have
been proven to lower stress.
5. Spend time in hot water. Warm
baths and hot tubs can soothe the
nervous system.
6. Talk to peaceful friends. Talking to
someone who doesn’t react to your
anxiety and who is in a different
frame of mind can remind you that
contentment is possible.
7. Find engaging sources of recreation. A
light-hearted or funny movie can
shift your entire mood.
8. Seek out other sources of income.
Bringing in even small amounts of
money, such as with consignment,
can remind you that you are
resourceful and that you will be okay.
9. Use your downtime from work. Take a
class, brush up your skills, pursue
creative projects, or simply get
more rest.
10. Plan for the future. Deal with the
realities of today, but keep making
plans for the future. Assure yourself
that things will get better. [
calm and well-being.
1. Give yourself a break. It takes
time to get used to diminished
circumstances. Accept your
feelings and talk to yourself in
soothing ways.
2. Focus on the good. When fear arises,
remind yourself of the stability in
your life: your savings, spouse’s
income, your own good health.
3. Exercise. Physical activity can
raise the mood and discharge
anxious energy.
4. Try yoga and meditation. Both have
been proven to lower stress.
5. Spend time in hot water. Warm
baths and hot tubs can soothe the
nervous system.
6. Talk to peaceful friends. Talking to
someone who doesn’t react to your
anxiety and who is in a different
frame of mind can remind you that
contentment is possible.
7. Find engaging sources of recreation. A
light-hearted or funny movie can
shift your entire mood.
8. Seek out other sources of income.
Bringing in even small amounts of
money, such as with consignment,
can remind you that you are
resourceful and that you will be okay.
9. Use your downtime from work. Take a
class, brush up your skills, pursue
creative projects, or simply get
more rest.
10. Plan for the future. Deal with the
realities of today, but keep making
plans for the future. Assure yourself
that things will get better. [
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