Maintain a sense of humour. While many behaviour problems really are serious and a cause of considerable stress for parents, keeping things in perspective is important. The fact that the child utters a profanity, or breaks a vase, isn’t necessarily the calamity that it appears to be at the time. Of course, it is still important to employ the strategies outlined below but the ability to laugh, and not to take it all too seriously, is one of the more important things to keep in mind as a parent. Give your child a choice where possible, but set limits on this. Often there is a blow-up in the morning, when you are in a hurry, and your toddler is holding everyone to ransom by refusing to wear the yellow shirt. A limited choice — ‘Which shirt would you like to wear, the yellow one or the red one?’ — will give your child a sense of control as well, and often avoids setting up a confrontation. Observe the two fundamental rules of behaviour modification: reinforce wanted behaviour, and ignore unwanted behaviour. Most parents generally do not pay enough attention to children when they are good, that is, they do not sufficiently reward and reinforce desirable behaviour. Try to catch your child being good, and let him know how pleased you are about it. Praise him verbally, or with a light touch on the shoulder, a cuddle, or even an unexpected reward, such as an icecream. Similarly, wherever possible and appropriate try to ignore undesirable behaviour (see Temper tantrums, p. 144). Obviously, there will be times when this is not appropriate. In these circumstances, use the ‘time-out’ technique which is described below.

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The working-through process

Recovery is not as simple as we would like it to be. In the beginning, it feels as though we take one step forward then two steps backwards. This is why so many people feel they are never going to recover. It is also part of the reason why so many people become discouraged and give up.

We need to understand the step-by-step process of working through the various stages of recovery. Understanding the working-through process is of the utmost importance, yet it is rarely discussed as an issue.

Patience

One of the first things we need to learn is patience. Everyone, naturally enough, wants recovery now. Not tonight, not tomorrow, not next week, but this very second. This creates further stress which keeps the whole cycle going. Whether we like it or not, we all have to learn patience, with the working-through process and with ourselves. Learning to be patient with ourselves is learning to be kind to ourselves. Being kind to ourselves means we are not putting ourselves under any further unnecessary stress.

We need to direct our energy into the determination to commit ourselves, time and again, to the working-through process despite setbacks.

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As we’ve seen, sleeping through the night is not as simple or common as we might assume.

? Arousals during the night are normal and need not cause problems.

? Sleep problems can arise when a child cannot put himself back to sleep after the arousals.

?    It may be harder for children to sleep undisturbed because a child goes more rapidly through the sleep cycles than an adult; there are more periods of arousals and therefore more chances to awaken.

?    Deep sleep occurs early in the night and again for a short while near morning. Sleep terrors are likely to happen at this time.

?    Light sleep and dreaming occur in the remainder of the night. Nightmares (vs. sleep terrors) happen during that time.

?    You can determine your child’s sleep state by her sleep behavior and by what time she went to sleep.

?    This information will help you assess the nature of the sleep disturbance and what your response will be.

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Feeling short of breath basically means that you are not getting enough oxygen into your blood. This could be because there is something wrong with the lung tissue itself—cancer in the lung, clots on the lung, pneumonia, radiation reaction, lung damage caused by bleomycin, or fluid building up in the lung because your heart is not working efficiently. Breathless-ness can also be due to the lung being squashed by fluid building up outside it in what we call the pleural cavity (the membrane-lined space between the lung and the chest wall). Partial blockage of some of the bronchial tubes can also make you feel short of breath. The blockage could be caused by cancer pressing on them or spasm (as happens with asthma). Breathlessness can also be a symptom of anaemia. When you are anaemic, your blood does not carry as much oxygen as normal, so you automatically breathe faster to try to get more oxygen into the blood. And, of course, nervous tension can result in a feeling of breathlessness, or aggravate breathlessness of any other cause.

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As well, the eye may water and the nostril on that side become blocked, then run with discharge.

The pain rarely lasts beyond three hours and is often as short as 30 minutes. Attacks may occur several times a day and often go on for days or weeks, then disappear.

During an attack, alcohol seems to precipitate the headache, or make it worse. In between attacks, alcohol has no effect.

Many sufferers seem to share a characteristic appearance. Their facial features are described as leonine (lionlike).

Once diagnosed, treatment lies more in prevention than using drugs to relieve the acute pain.

Drugs used in the management of migraine such as methysergide, pizotifen and ergotamine taken regularly, singly or in combination, can abort and prevent attacks.

Cortisone, used in a short burst, is also of considerable value. The betablocker drugs, originally introduced for use in treating heart disorders and high blood pressure, can be of benefit in preventing these attacks.

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It was suggested that hysterectomy should be carried out on all women beginning oestrogen replacement therapy so as to “keep young” … this operation is not a minor procedure and such advice did not find favor in this country.

Sometimes oestrogen may be given in cream or pessary form to deal with local changes in the genital area.

Oestrogens may cause bleeding and this can be a worry as the doctor may be uncertain whether the bleeding is due to the tablets or to a cancer. For this reason, all cases of post-menopausal bleeding need to be properly investigated.

A woman’s change of life should be accepted as part of existence and as an entry into a different world. No longer is there the fear of becoming pregnant and she should retain or increase her interest in sex.

Those who understand what is happening to their bodies have more chance of having a smooth and trouble-free climacteric.

Hormone replacement therapy is an important and now, relatively safe, form of treatment for menopausal symptoms. The oestrogen is combined with the other female hormone, progesterone, and is usually given in a cyclical fashion.

This does result in regular bleeding, like a period, but by getting rid of the lining of the womb with this bleeding, the risk of getting cancer of the womb is greatly reduced.

This treatment will prevent the development of osteoporosis and may also be protective for cancer of the breast.

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The most common type of diabetes (type 2 diabetes) is the result of insulin not working properly and usually affects people over the age of 40. Overeating, being overweight and not exercising enough are important factors (what we call lifestyle factors) which can lead to this type of diabetes, especially when there is someone else in the family with diabetes.

Many people who live in societies which are undergoing rapid westernisation are developing this type of diabetes. Why ?

To find the answer we need to look back in time. Our ancestors lived and evolved in a very cold climate. Over the last 700 000 years there have been many ice ages—the last ended only 10 000 years ago. During these ice ages there was very little plant food around and people had to hunt animals for survival. This gave them a lot of protein in their diet. In other words, during the ice ages our ancestors were carnivores (meat eaters). Their bodies adapted to this way of life to help them survive on this diet—and also to help them survive times when food was scarce.

As it turned out, this protein-based diet would also have protected them from developing diabetes. This is because the main way the body copes when there is not much carbohydrate (glucose) in the diet, is to make sure that the important parts, such as the brain, get what little glucose that is available. To do this the body makes very little insulin, because the brain can use glucose without insulin. Thus the body’s demand for insulin was very small.

Since the end of the last ice age there have been many changes to the type and amount of food that we eat. First, our ancestors began to grow food crops. Agriculture changed their eating pattern from one based on animal protein to one based on carbohydrate in the form of whole cereal grains, vegetables and beans. A dietary change like this would also have changed the sugar levels in their blood. While they ate a high protein diet, the sugar levels in their blood would not have risen significantly after a meal. When they starting eating carbohydrate regularly, the blood sugar level would have increased after meals. The amount by which the sugar levels in the blood increase after a meal depends on the G.I. factor of the carbohydrate. Crops such as wheat grain, which our ancestors grew, have a low G.L factor. They would not have caused much change in blood sugar levels, so there would have been no need to use up much insulin, either.

The second major change came with industrialisation and the advent of high speed steel roller mills. Instead of eating whole grain products, the new milling procedures broke up the grain into small particles, in fact it enabled us to produce flour so fine it resembled talcum powder. The end result was highly refined carbohydrate. We now know that breaking up natural grain seeds by milling leads to an increase in the G.I. factor of a food, and transforms a low G.I. food into one with a high G.I. factor. When this highly refined food is eaten it causes a greater increase in blood sugar levels. To keep the blood sugar levels normal, the body has to make large amounts of insulin. Many of the commercially packaged foods and drinks with which we now fill our shopping trolleys, have a high G.I. factor. All this strains the body’s insulin supplies.

Thirdly, the dramatic increase over the past 50 years in the quantity of high fat takeaway and fast foods that we regularly eat has made matters even worse. So to our already high G.I. foods, we have added a lot of fat as well. Eating a lot of fat will increase body weight, which in turn makes it harder for the insulin to clear the glucose from the blood. In other words the body becomes insulin resistant—resistant to the effect of insulin. Continually eating carbohydrate foods with a high G.I. factor places even more pressure on the body’s ability to keep producing large amounts of insulin to control the blood sugar levels. Add to this insulin resistance, and you have the perfect recipe for eventually exhausting the body’s insulin supply and developing diabetes. Recent studies from Harvard University have shown that diets with a high G.I. increase the risk of developing type 2 diabetes by two to three times.

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Following this, more sophisticated approaches have been developed incorporating cognitive behavioural techniques, more realistic goal setting, and a focus on dealing with relapses—by prevention as well as psychological refraining.

Cognitions, such as negative thinking patterns, can be more complex and much more difficult to deal with than simple behavioural habits. People can often give the appearance of smoothly gliding through life with very few complications, while underneath being deep in turmoil. There are a range of ways psychologists deal with this from psychoanalysis to group therapies. Many modem psychological practices, however, now recognise that it is thinking about what may happen as much as what actually has or is about to happen, that causes many pathologies, phobias and simple unconstructive behaviours. This is not new. Indeed, there are a range of historical quotations dating back to 500BC which suggest that this is the case. These provide a clue as to the appropriate means of dealing with major cognitive problems.

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De novo lipogenesis is the term used for making fat from other nutrients such as carbohydrate and alcohol. De novo lipogenesis is not thought to have a significant role in humans under normal physiological (day-to-day living) conditions.

• Unlike carbohydrate and protein, fat is not finely balanced in the body.

• Fat (from the diet and adipose tissue) is the energy buffer for the body—it makes up the difference between what the body obtains from non-fat calories and what it needs.

• Alcohol is the highest priority fuel for burning, but unlike protein and carbohydrate, it does not reduce hunger.

• Energy balance and fat balance are essentially equivalent.

An anecdotal survey of people living in the modem world reveals an interesting paradox in energy balance. On the one hand, it seems that the body has an excellent, in-built energy balancing system which for some people keeps them at the same body mass, or at least within a variance of about 1 per cent, over decades. This is a remarkable feat if one considers that over a

10-year period the body can balance about 10 million kcal in, with 10 million kcal out, without the individual having to consciously count a single one! On the other hand, for some people, this system seems to go very wrong as they gain fat over time, despite their best conscious efforts not to. Has the system broken down in these people? This seems unlikely and the probable resolution of the apparent paradox is that the body has excellent balancing mechanisms for all types of calories except one—fat. So high-fat diets and low fat burning can result in fat gain without the usual energy balancing systems detecting it, because they are not designed to detect it.

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Some babies from birth make a strange rasping noise when they breathe. It may be more noticeable when they cry. There are many causes, and the doctor will try to discover the underlying reason, and have this corrected if possible.

Infections of the voice box are the commonest cause. (In serious cases this may develop into croup, as previously described.) Foreign bodies the infant has inhaled, or structural abnormalities that occurred during baby’s development, all may play a part.

Noisy breathing is the key symptom. The parent may notice that when the infant breathes, the area between the ribs seems to suck in. Hoarseness, breathing difficulty, and a ‘laryngeal crow’ (this is a strange crowing noise when baby breathes) may be present.

Treatment

If any of these symptoms are present, they need a full check by the doctor. When the cause has been found, the doctor will work out the necessary treatment. It will vary with the individual; and as treatment varies with cause, it is a matter of tailoring the therapy for the young patient.

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