Off the Quill 2019-2020

OFF

THE

QUILL

2019-2020

OFF THE QUILL

HONORS RESEARCH AND

CREATIVE ARTS JOURNAL

VOLUME 15

2019-2020 EDITION

OFFICE OF HONORS PROGRAMS

TEXAS WOMAN’S UNIVERSITY

COVER ART

Face of Future

Caitlyn Laky

CONTRIBUTORS

PUBLICATIONS SECRETARY

Amanda Greenwood

LAYOUT EDITOR

Anissa Clark

JUDGES

Amanda Greenwood

Anissa Clark

Alyssa Lumsden

Julia Hodges

Lindsey Blevins

Nicole Nguyen

Sarah Pham

TABLE OF CONTENTS

CREATIVE

Preserved Golden Dreams

Blair Baumann

Neha

Katelyn Garst

Conqueror of Contemplation

Caitlyn Laky

Bursting Waterballoon

Sarah Pham

The Dead of Winter

Sarah Pham

Golden Castle Over Water

Sarah Pham

Mountaintop Sunrise in Hawaii

Sarah Pham

Shadows

Sarah Pham

Zebra Stripes

Stephanie-Grace Makayabo

To: You, The Reader

Samantha Salcedo

I Should Have Eaten the Sandwhich

Jenna Seachman

OUTSTANDING CREATIVE SUBMISSION

Ode to Naps

Jenna Seachman

2

3

4

5

6

7

8

9

10

11

14

16

POETRY

Melancholy

Ryan Atbin

Autumn

Amber Gaudet

Morning

Amber Gaudet

Hourglass

Dreanna McAdams

Rooms of Persona

Dreanna McAdams

This Is Not Art

Jenna Seachman

Love and Energy

Joanna Simmons

Spring Serenity

Joanna Simmons

OUTSTANDING UNDERCLASSMAN

Mosaic

Alyssa Lumsden

19

20

21

22

23

24

26

27

28

RESEARCH

Silver Diamine Fluoride Versus Restorations in

Primary Dentition

Blair Baumann

The Ethics and Effects of Involuntary Treatment of

Mentally Ill People

Anissa Clark

A Call for American Sentencing Reform

Amanda Greenwood

Child Abuse in Texas

Eve N. Miller

The Effect of Music Therapy Combined with

Equine-Assisted Activities on Physical and Communication

Skills of a Woman with Stroke-Induced

Quadriplegia: A Pilot Case Study.

Heather Mock

30

41

51

60

68

Treatments and Causes of Idiopathic Hypersomnia

Yurimar Santiago-Torres

Obesity: Genetics or Epigenetics?

Lily Sebastian

Stone, Steel, and the Art of Propaganda:

A Comparative Study of Augustus of Primaporta and

Soviet Worker and the Collective Farm Woman.

Abby Weatherford

OUTSTANDING UPPERCLASSMAN

Orientalism and the Construction of the Victorian Identity

in Arthur Conan Doyle’s Sherlock Holmes series

Amber Gaudet

OUTSTANDING CAPSTONE 2019

Ups and Downs: A Documentary Exploring the Oral

Histories of Two Families with Children

who have Down Syndrome

Marisa Jean E. Patterson

84

92

99

119

128

CREATIVE

1

Preserved Golden Dreams

Blair Baumann

2

3

Neha

Katelyn Garst

Conqueror of Contemplation

Caitlyn Laky

4

5

Bursting Waterballoon

Sarah Pham

6

The Dead of Winter

Sarah Pham

7

Golden Castle Over Water

Sarah Pham

8

Mountaintop Sunrise in Hawaii

Sarah Pham

Shadows

Sarah Pham

9

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Zebra Stripes


10

To: You, The Reader

Samantha Salcedo

To: You, the Reader

Subject: Answering THAT Question. . .

Dear Reader,

That question. . . You know the one. The question that you’ve

been asked since you were old enough to glue two pieces of paper

together. “What do you want to be when you grow up?” And

of course the responses of future princesses, presidents, and pop

stars were met with the smiles of adoring parents everywhere.

That question that seems to have evolved in diction but not so

much meaning as one entered high school: “What are you going

to major in?”. That question which will determine how you spend

the rest of your life on this earth. It took me a while to figure out

what I wanted to do, who I wanted to be. I knew I wanted to do

something that excited me, that made me want to get up every

morning. It took me seventeen years but I finally figured it out

what I wanted to be, or rather what I never wanted to be.

I never want to be ordinary.

As cliche as I know that sounds on the surface, once you unpack

those six words they can mean so much more than an some Instagram

model’s selfie caption. In my case, it’s means that I never

want to lack the magic that can change the humdrum of the dayto-day

into something beautiful and exciting. I grew up on science-fiction

and fantasy. So I find myself craving extravagant, life

endangering, magical adventures. I want to be swept into worlds

filled with magic and things that I know I can only experience

through books or movies. Finding peace with the fact that I will

never get to explore deep space in my lifetime, learn to fly, duel

magical beasts, or save the world was something that was harder

to do that I would like to admit. But after a lot, maybe too much,

contemplation about finding the magic I so craved, I decided to

focus on a career that could bring me new, fast paced, adventures

every day. I decided I wanted to follow in my mother’s footsteps

11

and become a nurse.

It took me a long time to realize that I can have all the adventure

and magic I could have ever wanted in my seemingly normal

life. Magic doesn’t have to be a bearded man with a funny hat, or

a young girl with an ancient bloodline. Adventure doesn’t have

to be fighting magical beasts, or traveling to discover untouched

planetary systems. Both of those things can be found in the nursing

career I want to spend my life pursuing. Now, I told myself

that I would not settle when it came to my career. You know, the

thing I was going to do for the next sixty years, the thing that

would put food on my table and keep a roof over my head when

I’m old and grey. I found a job that brings me the action and

adventure I seek, but also a little magic. I can find life’s little magics

in the eighty-five year old man who I recitate so he can say

goodbye to his children and wife. I can find little magics in the

ten year old girl who just had life saving surgery and her smile

after I hand her her favorite stuffed animal. I can find those little

magics in the people that I help, and that I save. I can find adventure

in the rush of adrenaline I’ll receive when a new patient

comes through the door. I can find adventure in the commotion

of a code blue.

I CAN have all I ever wanted.

Once you realize that you can have everything you desire, every

piece of your most fantastical dreams, your whole attitude about

life shifts. I know, in the deepest part of me that if I keep chugging

forward, if I stay in school, if I push myself to get out of bed

on the days where I feel I’m being suffocated by routine and by

my ordinariness, if I keep moving forward . . . I can make my

life something I’ll be proud that I lived. And heck, If I can do it,

then so can you! You can change your entire life with a single

thought: You can have anything and everything you want. I encourage

you to find something that gives you that gut feeling you

only experience when reading or watching fiction. Find a career

or opportunity that excites you the same way Quidditch or space

travel does. Find something that you know, in the deepest part of

yourself, will bring you life’s tiny magics and adventures. It took

12

me seventeen years to find that something, and I hope this helps

you find yours.

However, I must acknowledge the fact that not everyone will be

able to fill the void of the everyday with the joy their job brings

them. Many will settle for a desk job, in a building with atrociously

colored carpet and a boss who never remembers their

name. Perhaps they settle out of defeat or out of necessity. They

are the ones who have to find that otherworldliness in different

places. Maybe you’ll find it in a lover, someone who conjures

such adoration from you they are magical in and of themselves.

Maybe you will find the mystical in oil paints or charcoal pieces.

Maybe you’ll find magic amongst the sharps and flats. Maybe just

maybe, you’ll find adventure in a child of your own. Wherever,

or however you find your magic, your adventure, or your fantasy

I hope it satisfies you. I hope it consumes you and brings a smile

to your face. I hope you relish in that joy and remember it in the

times where the mystical seems so far away. I hope you cherish

what you have discovered and know, that you have found something

so marvelous some can only dream of finding what you

have.

I hope you never give up on magic.

~

I hope you never give up on adventure.

~

I hope you never give up on the fantastical.

~

I hope you never let the world tell you you’re too old.

~

I hope you find exactly what you’re looking for.

-Sammy

13

I Should Have Eaten the Sandwhich

Jenna Seachman

Sometimes even the smallest things we keep become

priceless.

I remember this like it happened yesterday. It’s a

little faded around the edges — as if between that ‘yesterday’

and ‘today’ was a very deep, and very restorative

night’s sleep — but I can still see myself sitting at Chickfil-A

after my night shift.

It was a few months after my first breakup. I was

at Chick-fil-A… with my ex-boyfriend. Who also worked

there at the time. It had been two months since we broke

up. He never fully explained why he broke up with me,

but that day, when I asked him, he finally agreed to tell

me why. I got off the clock at ten; he was closing.

I was sitting at the table right next to the cash registers.

While I waited for him to finish cleaning the icecream

machine — his assignment for the night — I got out

my phone, turned on my Notes app, and journaled to clear

my head.

As it turned out, I kept that tiny snippet of a memory.

I put it on my laptop, in a document full of journal

entries. Today, when I was scrolling through, I found it

again.

I’ll refer to my ex-boyfriend as ‘the guy’ here.

My purse is open in front of me, along with my hat and

a huge bag of cold Chick-fil-A extras. And also [the guy’s] huge

sandwich he went to the back to get. In front of me Stephen is

counting a till, and everyone else is closing. The squeegeed floor

is gleaming in the fluorescent lights. [The guy] is cleaning the

ice cream machine. I have this super deep line in my forehead

from wearing my hat too tight. And I’m just sad. I don’t know

what’s going on. [He] agreed to talk to me. I’ve been waiting

editing photos and trying not to lose my mind. I swear, if he

doesn’t come over in the next five minutes, I will literally eat his

giant double-filet bacon sandwich out of pure spite, and it might

just be the best sandwich of my life.

It’s been half a year since then. And I have so much

14

love for this girl. This girl who thought that closure would

solve all her problems. This girl who was about to watch

the person who once called her the love of his life shake

his head at her unworthiness. The girl who would hear

things about herself and her worth that were so clearly

untrue.

This girl thought that that night at Chick-Fil-A

would be a huge step towards her healing process — and

maybe it was, but it was also an uncovering, like ripping

off a bandage, revealing the full scope of how much healing

needed to be done.

But I can’t really pity this girl. Because this girl was

blessed with dreams. She wanted to be an author one day,

and so her first instinct, when she was stressed yet aware

that a story was unfolding, was to describe the world

around her. This girl filled journals upon journals, her

words spilling onto her computer when she had no more

paper to write with. She healed as she wrote, or maybe

she wrote as she healed, until she became the person she is

now.

I can’t help but love this girl. It’s a relief, then, after

struggling with self-worth for so long, that this girl is also

me.

And I’m happy to be her. This was just a tiny snapshot

of the growth I’ve had in the past few months, and

even though I still have traces of sadness, they’re no match

for my joy.

I once heard a poet say that closure doesn’t come

right after someone leaves — it comes after learning why

you should stay away from them.

It’s been a long time. The sleepless nights have given

way to restful ones. I have all the closure I need, and I

hope he has that closure too.

15

OUTSTANDING CREATIVE SUBMISSION

Ode to Naps

Jenna Seachman

If we are what we repeatedly do, then I most definitely am

a nap.

Let me elaborate: I am a long, luxurious nap, taken

under several layers of blankets, with a diffuser peacefully

dispersing its contents in one corner, and perhaps the

peaceful hum of a neighbor’s lawnmower outside. The

kind of nap where you wake up restored and ready to

conquer the world, like you may or may not have manifested

superpowers… and also with several pillow lines

on your face (the mark of a truly great nap, in my opinion).

And if I am a nap, then that also makes me a rare

commodity — especially during the school year. Winter

and summer breaks are when I thrive. Because during

the school year, nobody has time for one of those double-down,

hardcore naps — you know, the kind where

you do a miniature interior decorating session beforehand.

Where you walk around the house thieving blankets from

every corner, then stockpile your pillows, shut the curtains,

and spend ten minutes ransacking your drawers until

you find your sleep mask. Then you arrange everything

— oh, and don’t forget the diffuser — in its proper place,

and bam. A nap-oasis.

When I’m in the middle of the school semester, and

I have three assignments due, a speech to give, and a powerpoint

to make, the nap oasis is a distant mirage, despite

the fact that this is the number-one time I’d love to be mercifully

unconscious. No — just like my actual life, school

breaks (and weekends) are the only time when naps can

be enjoyed in their entirety.

Really, the similarities between me and naps are

endless. Except when it comes to power naps — aka those

thirty-minute pops where you jump into bed and then

trampoline out of it thirty minutes later. At least, a tram-

16

poline is what it would take to get me out of bed after

only thirty minutes of napping. Or maybe an ejection seat,

because that wouldn’t require any bouncing. I’m not even

sure what ‘power’ a power nap is supposed to give you.

Disappointment? In my opinion, a power nap would just

intensify the longing for my pillow-covered queen-size.

I’d probably go stare out a rain-streaked window like the

heroine in a rom-com, waiting for my lost love to appear

on the horizon.

I wrote this essay to make you laugh — but also to

remind you to take stock of your priorities. Glance at the

pile of books on your desk, the long list of assignments

that need to get done. Ask yourself: when’s the last time

I took a break? If the answer is ‘when I passed out at 4 in

the morning after chugging two redbulls so I could finish

my paper in time’, or something along those lines, I highly

suggest that you add a new bullet point to your to-do list.

Call it what you will. “Rest.” “Time for peace.” “Maintaining

sanity.” “Jenna Seachman.” No matter what it is,

though, it’ll mean the same thing — a really well-deserved

nap.

17

POETRY

18

Melancholy

Ryan Atbin

What is it like traveling through a gorgeous world like

this?

Elegant, graceful, luxurious?

Walking through the vivid night,

Watching my only partner in the mirror of water.

It is lonesome.

What is the point of this artistry

Without the delicacy of a loved one?

Mustering an insipidness environment

In this already bright world.

No amount of light can bring you out of

The darkness of isolation.

I walk, alone, in the loveliness,

Creating a melancholic tone in the wind.

Only when I find the beauty in my better half

Will I be able to find the beauty of the world.

19

Autumn

Amber Gaudet

I let the eggs rot in the trunk

The first thaw in a week-long winter

Sitting with myself and the new sun

Breathless with recalling

The scrape of an old poet’s reciting

How a wren’s trill could fill the morning

With the weight of apology

For shattered sleep

How I could shake off this loss and emerge

Somehow, unafraid

With the warmth, a return

20

Morning

Amber Gaudet

I wake in the crease of your long arm

Stretched across the cheap bedsheets

The expanse of cotton damp with sleep

Wholly myself in this place

I marvel

At the weak winter sun,

The cry of a neighborhood cat

As it breaches the mottled brown tree line,

That we made a home of our regret

To spite it, even

Unburdened

In the reprieve of one another

21

Hourglass

Dreanna McAdams

Some part of me wants to believe

that things can return to the way they were before.

That a glass can unbreak-

The same sun can rise again-

That autumn leaves can fall in reverse.

It is meaningless to wish back time

But I do.

I wish and I wish and I want

To forget today and return to a time where

I was young.

But as I grow older, I remember

that a glass broken

reflects the gentle moonlight

of the sun now gone for the night;

one that will rise again and set the amber fallen leaves

aglow.

And someday, when all wounds are healed,

I will stand and stare at new, green leaves

framed by rays of the warm spring sun,

and watch the light reflecting off the glass nearly buried in

the earth

and smile at the gift

of a constantly ticking clock.

22

Rooms of Persona

Dreanna McAdams

The rooms persona are all a part of me.

When the door creaks open, which one do you see?

Order.

Black and white, sleek edges.

No dust, and citrus scents.

Standing tall, with gentle nods and polite smiles,

An ode to decorum and simplicity.

Bright light.

Mild cluckles and chuckles of birds as the morning begins.

Flowers and earth and vibrant tomato vines

Their smells, altogether overwhelming and soft.

A verse to the earth, of humility, content, and abundance.

Rust and metal.

The sharp smell of sweat and damp metal in the dewy

morning

And the sound of ringing metal before the sun has risen.

Contained anger, released.

Cathartic pain, adrenaline rushing, escape.

The smell of ash and vanilla,

Flipping pages of old, coffee-stained books.

Dust flutters in the sunlight of small windows

That peek from between huge shelves of multicolored

books.

Gold writing, bold writing, a messy mind and wide-eyed

wisdom.

The rooms persona are all a part of me.

When the door creaks open, which one do you see?

23

This Is Not Art

Jenna Seachman

To the ones who never fully learned how to value themselves.

Maybe it was how you were raised.

Or how you were treated outside the home.

Or maybe there is something sadly peculiar about you,

that the love you received never sank in deep enough.

Regardless of the source, all the people, circumstances,

and flawed mentalities you’ve known have painted

their own pictures of you. You’ll lean these portraits on

your nightstand, set them on your dresser, and hang them

on the wall — believing that they are the most accurate

depictions of yourself that you’ll ever receive.

Your likeness has been painted by dozens of people.

By parents and friends and lovers and ex-lovers and

extended family members; even strangers you locked eyes

with just long enough for them to mirror their opinion

back to you.

You gather these paintings. They fill your room like

a starving artists’ loft, leaning against every surface, until

you can barely see the walls.

The faces look back at you, similar but different,

unique but the same. Your faces, painted by the people

you’ve known.

Some of your paintings will be ugly. Others will be

beautiful. Some are particularly bad — like the one painted

by your ex-boyfriend, or the boss who never liked you.

The picture painted by your high school crush, who never

really noticed you, is only the faintest, grey impression of

watercolor, and yet it brings tears to your eyes.

I know why you’ve kept these pictures. I know

their twisted allure. I know the temptation to believe that

the ugly ones are the most accurate. In fact, if you’ve given

in to that temptation, like I have so many times, you’ve

moved them to the front of the collection. They’re the faces

that stare at you the most, and the hardest.

24

Today, I humbly ask you to take these paintings

down. The one painted by that boss. The one by the girls

or guys who never liked you. The one by your absentee

parent or the sibling that never really cared. I want you

to throw them all away. Because contrary to what these

people may tell you, this is not art. Not even close.

When these paintings are gone, you’ll be left with

the ones underneath. The canvases painted by your mother

who loves you; your sister who looks up to you; the

classmates you shared your notes with on finals week; the

friends you’re constantly checking up on; the strangers

whose day you brightened with a smile; the teachers who

both admire and are flattered by your curiosity in class.

Blow the dust off these paintings. Lean them on your

nightstand, set them on your dresser, hang them on the

wall.

After you’ve done it, you can’t help but stand back

and admire these canvases, this collage of you that makes

your bedroom look like a thriving artist’s loft. All are different

and unique, and yet the same.

This is art.

Because you are art.

25

Love and Energy

Joanna Simmons

I love when the sun shines

gloriously golden orange

through my window

calling me from dreams

before any disorder can stir me.

Light peeks through blinds,

soft lines; it is a slow awakening,

My heart first

then my mind

my limbs and

my eyes.

I lay still

afraid to lose

the quiet inner glow.

I let the morning’s peace

settle

On top of me

and think of how

in my dream,

you were next to me,

and in my sheets.

I still feel you there

Where the light is.

26

Spring Serenity

Joanna Simmons

Somewhere there is chaos,

But not here.

Here the air is light to touch; black birds paint the silence

With their melody—

The sound of light hearts and

A creeping summer’s rest.


Death, darkness

But not here.

Here, there is the heartbeat of the sun

And the breath of the earth

On my skin.

Laughing colors, living shades of

Blue, brown, green.

Time stops when I blink,

And my eyes conjure stars

As I hold them too tightly;

The universe is in sight.


And one day it may find way to me

But for now, I am still

And my heart does not ache at the emptiness.

My soul does not cry at the weight it bears.

I am at peace

Like the rest of the world longs to be.

27

OUTSTANDING UNDERCLASSMAN SUBMISSION

Mosaic

Alyssa Lumsden

Sand pressed tightly between calloused hands

eventually forming tiny shards of glass.

Time and pressure creating a clear oasis.

Sharp and steady.

Perfect panes wither with stress and age.

Those come and go testing its strength.

The glass breaks.

Cracks.

Shatters.

Left worthless to

litter the grounds of the earth.

An artist approaches.

A mind of wonder.

He takes the glass and rearranges.

Reforms and repurposes.

With care and patience

a masterpiece is born.

Now proudly hanging on display

is a mosaic.

A spectrum of colors illuminated

through many fragments.

Brokenness made whole.

28

RESEARCH

29

Silver Diamine Fluoride Versus Restorations in

Primary Dentition

Blair Baumann

Abstract

This research involves a patient with occlusal and proximal

caries on a molar experiencing sensitivity. The patient

is three years old and lower socioeconomic status. Thus,

for a patient with early childhood caries, how does silver

diamine fluoride as compared to restorations treat carious

lesions? Generally, silver diamine fluoride is cheaper

compared to restorations (Johnson, Serban, Griffin &

Tomar, 2019). SDF leaves behind a permanent spot but

demonstrates a significant amount of caries arrest (Tedesco

et al., 2018). Restorations, which are typically chosen as

tooth-colored, may be more aesthetically pleasing (Aldlaigan,

2015). Restorations are effective in disposing of

carious tissue and restoring the tooth (Chisini et al., 2018;

Cumerlato et al., 2019; Domnez et al., 2016). The patient’s

guardians value a low-cost, quick treatment. The clinician

has personal experience with restorations but no true clinical

experience with either option. Addressing the problem,

SDF will be recommended for arresting caries along with

patient care to prevent future decay. The search strategy

involved the treatment in relation to primary dentition

through the MeSH term and for applicable information.

Cochrane and EBSCOHost were the primary databases

used to find high-quality evidence, which includes a few

systematic reviews, surveys, experimental clinical trials

and meta-analyses.

Caries for a child means the possibility of inhibiting

the proper growth and mineralization of the permanent

dentition without proper intervention (Tedesco et al.,

2018). Silver diamine fluoride is a newly approved intervention

of the FDA in 2014 that arrests caries through

topical treatment (Horst, Ellenikiotis, UCSF Silver Caries

Arrest Committee, & Milgrom, 2016). In comparison, cari-

30

ous lesions are typically treated with restorations through

the removal of the harmful tissue and the subsequent

application of restorative materials (Tedesco et al., 2018).

The selection of either SDF or restorative work requires

the analysis of the effectiveness, procedure, cost, and perceptions

with each option. Ultimately, however, in choosing

a proper treatment, the decision must be made with

the patient’s preferences in mind in conjunction with the

clinician’s experience and scientific findings from peer-reviewed

literature.

Patient Information

The patient discussed in this paper is not real and

is made up by the writer for purposes of this assignment.

The patient is a three-year old female who has recently

moved to the United States from Mexico with her family.

Due to the family’s situation with this recent transition,

the parents have not been steadily employed and therefore

lack dental insurance. Their chief concern at this point is

the sensitivity and pain of the patient’s molar. At this time,

the patient has demonstrated no signs of any systematic

health conditions. In regards to dental health, the patient

has had dental hypersensitivity in the past when eating

certain foods, as indicated by the chief concern.

The parents have also indicated on the dental history that

the patient does not brush regularly. Upon initial examination

and radiographic images, a dentist has diagnosed

the patient with occlusal caries and incipient proximal

caries on the first molar in the lower right quadrant.

Patient’s Preferences and Values to Consider

When considering treatment options between restorations

and silver diamine fluoride, there are a few things

that need to be taken into consideration. The first element

to consider is the patient’s preference of not wanting to

spend a lot of money on treatment. The parents have

emphasized their lack of interest in an expensive procedure,

especially with primary dentition. Another concern

of the parents is having a low amount of maintenance and

31

follow-up appointments due to their lack of insurance.

Therefore, it is essential to consider the time period of the

treatment during selection. An additional preference to

consider a short procedure time as well since the guardians

have expressed their concern for keeping the patient

still for too long.

Clinician’s Experience and Judgement

The clinician is currently limited in knowledge of restorative

dentistry and practice with the application of silver

diamine fluoride. However, the clinician has taken on a

community-based project initiative with silver diamine

fluoride and subsequently is more familiar with the procedure,

risks, and general cost-effectiveness. Since the

clinician is aware of the impact of this intervention for

the community in regards to a lower-cost solution, the

clinician will most likely consider this due to the patient’s

current socioeconomic status. In regards to experience

with restorations, the clinician recalls personal family

experience of longevity with stainless steel restorations

that have been retained for many years without any diagnosed

recurrent caries or pathology. However, this is only

personal experience and should not take the place of any

evidence-based research within the dental field.

Answer Based on Findings in the Literature

Silver Diamine Fluoride

Silver diamine fluoride is a procedure used to arrest

carious lesions through remineralization by way of the

fluoride and an antimicrobial agent through the silver

compound to help stop the progression of disease (Horst

et al., 2016). This is a topical treatment that requires minimal

application time and maintenance (Horst et al., 2016).

Effectiveness and treatment. As previously stated, SDF

works to not restore but to instead stop the progression

of caries and the resultant demineralization of the tooth

(Firouzmandi, Shafiei, Jowkar, & Nazemi, 2019). Although

it may not be able to necessarily restore the tooth, SDF has

been shown to increase the hardness and elasticity of the

32

tubules (Firouzmandi et al., 2019). According to a systematic

review of the management of caries in pediatrics,

it was concluded that the best noninvasive treatment for

occlusal caries was the application of 38% silver diamine

fluoride due to high arrest rates (Tedesco et al., 2018).

In regards to the field of dental hygiene, this provides

an alternative to the restoration of caries and an option

for those who can not afford a more invasive procedure.

Instead of fully restoring the tooth, tooth strength can be

enhanced in addition to the stop of the progression of disease

(Firouzmandi et al., 2019).

Cost. In regards to cost, there is a consensus within

the dental field that this intervention is more readily

accessible for patients. However, it is essential to denote

the context of the use of this intervention. It was determined

that for Medicaid payments, overall expenditures

can be significantly reduced when treating primary teeth

with silver diamine fluoride as opposed to other conventional

methods (Johnson, Serban, Griffin, & Tomar, 2019).

Overall, the benefits, including penetration ability and the

number of averted follow-up visits, outweighed the general

cost of subsequent visits in cases where the application

proved to be initially ineffective (Johnson et al., 2019). This

applies to the patient in regards to a lower socioeconomic

status. Furthermore, this once again emphasizes the move

towards flexibility of care in the dental field by providing

an affordable option to take care of the natural dentition in

the face of decay.

Concerns and perceptions. Since the patient is a

child, it is necessary to understand parental satisfaction

and approval of this intervention. With this intervention, a

dark spot where decay occurred will appear after the application

of SDF, which is useful in analyzing the success

of the procedure (Horst et al., 2016). An aesthetic concern

with silver diamine fluoride tends to be the permanent

black lesion left behind on the treated tooth (Jiang, Wong,

Chu, Dai & Lo, 2019; Vollú et al., 2019). It was determined

however that there is no true significant difference with

perception or satisfaction of this permanent dark spot

33

according to a handful of clinical trials (Jiang et al., 2019;

Vollú et al., 2019). In those same trials, it was also concluded

that there was no significant impact on oral health-related

quality of life (Jiang et al., 2019; Vollú et al., 2019).

This evidence is significant to the field since it provides

an argument against the aesthetic concern associated with

this treatment. It should be noted that the patient’s carious

lesion on the primary molar on the occlusal surface that is

to be treated will not be visible enough for most to see the

dark spot and the tooth will eventually fall out anyway.

Thus, the importance of arresting the caries is more essential

to overall health rather than any outlying concerns

over aesthetics.

Restorations

Conventional restoration, such as amalgam fillings,

is a procedure that uses rotary burs in conjunction with

instruments to remove the invasive carious lesion (Dorri

et al., 2017). Atraumatic restorations are typically used for

pediatric patients due to their minimal invasiveness and

involve the elimination of carious tissue through instrumentation

(Jiang et al., 2019). Both are commonly used

practices for the treatment of caries for children (Dorri et

al., 2017).

Effectiveness and treatment. Treatment with restorations

include the removal of carious tissue, either with

excavators or rotary instruments, followed by polyacrylic

acid wash drying, and then some version of a glass ionomer,

composite or stainless steel for full restoration (Dorri

et al., 2017). The success of restorations however tends to

vary depending upon the material used. A review conducted

that the highest overall success occurred with Class

I restorations and the use of stainless steel (Chisini et al.,

2018). Throughout the literature, there is a strong emphasis

on recurrent caries having the most impact on survival

of the procedure implying the need for proper patient education

and maintenance (Chisini et al., 2018; Cumerlato

et al., 2019; Domnez et al., 2016). In regards to the patient,

this means a drastic change in consistency and dedication

to proper home care. In regards to both atraumatic and

34

conventional restorations, there is no proven difference in

longevity; however, patient care and anatomy seem to be

the determining factors of success once again (Meyer-Lueckel,

Machiulskiene, & Giacaman, 2019).

In regards to longevity, it is essential as a consumer

of research to analyze criteria associated with restorations,

such as survival rates, success or claims (Laske, Opdam,

Bronkhorst, Braspenning, & Huysmans, 2019). In general,

failure rates for restorations based on success and survival

factors tend to be a more accurate representation of the

procedures (Laske et al., 2019). For a study including a review

of data from over a 100 restorations with a 3 year follow

up, it was concluded that Class II restorations tend to

present an average 5% failure rate based on success and a

2.9% failure rate based on survival, which becomes a consideration

for the patient’s proximal decay (Laske et al.,

2019). This significant to the field of dentistry in utilizing

restorations because it highlights the benefit of restoration

in longevity and the support as to why a patient may need

a more invasive procedure (Laske et al., 2019).

Cost. In regards to cost, there seems to be a few aspects

to restorative dentistry that must be considered. The

primary expense however is the price of anesthesia that

accompanies conventional restorations. Bills for children

receiving anesthesia or nitrous oxide range from about

“$100 to $600 and $1,000 to $5,000 per visit, respectively”,

which may be a deciding factor when selecting a specific

treatment for the patient (Johnson et al., 2019, p. 218).

This is also an important consideration in the dental field

as rising healthcare costs may be the difference between

government-funded support of only certain treatments

rather than others (Johnson et al., 2019). This implies the

need for pro bono service work, advocating for more community-based

programs through the field and emphasis

on patient education to promote the benefits of expensive

procedures.

Concerns and perceptions. Once again, parental

perception and concerns are taken into consideration with

restorative comparisons. With restorations, the primary

35

issue is discomfort due to sensitivity, sounds or high temperatures

(Dorri et al., 2017). Conventional restorations

also have the added burden of anesthesia, which holds

high-risk factors for patients (Dorri et al., 2017; Johnson

et al., 2019). This suggests that the dental field as a whole

needs to push for continued individualized healthcare so

as not to put patients in harm’s way due to their personal

risks. With the young age of the patient, anesthesia has

the potential to be dangerous even. In addition, the noted

dental hypersensitivity of the patient would contradict the

nature of the restoration procedure.

In regards to appearance, restorations have a wide

range of appearances for color, shape, and size (Aldlaigan,

2015). In a non-experimental study conducted

with pediatric dentists, the majority of the participants

stated that tooth-colored restorations are more common,

implying that the treatment would provide the patient

with a molar that appears more normal (Al-dlaigan, 2015).

However, this same sample also reported that for that

stainless steel is generally the material of choice for caries

involving more than one surface and the patient currently

has diagnosed occlusal and proximal caries identified at

this time (Al-dlaigan, 2015).

Evidence-Based Decision for Patient Care

Based on the patient’s preferences and values, the

clinician’s experience and the findings in the scientific

research, the best treatment option for the carious lesion of

the patient is the application of silver diamine fluoride.

To begin, the patient is specifically sensitive, which relates

to the chief complaint and the main priority of the

patient/guardians. Thus, the silver diamine fluoride is a

topical treatment and will not initiate the fear and pains

associated with the drilling and dangers of conventional

restorations (Dorri et al., 2017). Furthermore, the patient’s

parents expressed the desire for a low-cost solution which

relates to silver diamine fluoride being cheaper in regards

to less maintenance dental visits and no anesthesia expense

as associated with restorations (Johnson et al., 2019).

36

To provide individualized care, the patient’s needs and

desires should be addressed effectively through SDF.

The clinician has very little clinical investment or

evidence-based knowledge of restorations. The only indication

of experience with restorations is correlated with

personal observations and anecdotes from family members

of supposed longevity. On the other hand, the clinician

has already researched peer-reviewed journals and

evidence regarding SDF and the limitations, contraindications

and treatment procedure. Although there is no clinical

experience, the clinician is well-versed in the nature of

SDF, the benefits and the eligibility needed for application

and will use this knowledge to educate the patient during

the procedure.

Finally, the scientific findings indicate that the

overall benefits and procedures of SDF are more beneficial

for this specific patient. To begin, SDF is overall a lower

cost option due to the nature of the procedure as a topical

treatment and lower overall expenditure for follow-up

appointments (Johnson et al., 2019). In other words, SDF,

when applied correctly with the right percentages, serves

as more of a temporary and effective solution in terms of

expenditures (Johnson et al., 2019). This directly relates to

the patient’s familial situation of lacking dental insurance

and the parent’s request for a low-cost treatment because

of their lower socioeconomic status. It also correlates with

the clinician’s prior experience and knowledge of SDF

benefits in community outreach and lower socioeconomic

settings. Next, SDF tends to be a safer option against typical

restorations due to the elimination of the risk associated

with anesthesia and drilling (Dorri et al., 2017; Johnson

et al., 2019). This is important for this patient since they

are already young in age and experiencing sensitivity

issues as well as trouble sitting still. Although a dark spot

will occur as a result of this treatment, the patient will

have a much easier time going through this procedure and

will benefit from the clinician’s knowledge of SDF and the

scientific evidence on the high arrest of caries (Tedesco et

al., 2018).

37

In summary, SDF is the best option due to the patient’s

preferences of a safe, low-cost treatment in conjunction

with the clinician’s past research experience with SDF

and the scientific literature emphasizing the effectiveness

of this safe topical treatment and the effects on the carious

lesions. With this care plan in place, the expected outcome

for clinical purposes would be the arrest of the carious

lesions on the affected molar and a permanent dark lesion

representing the area that was previously decayed on the

occlusal and proximal. In addition, the SDF topical procedure

should be implemented in conjunction with patient

education in an attempt to prevent future caries, such as

discussion regarding diet, hygiene habits, and home care.

Thus, the final outcome should also include patient and

guardian knowledge and understanding of how to better

care for the oral cavity to help promote overall health and

well-being for years to come.

References

Al-dlaigan, Y. H. (2015). Pediatric dentist’s choice of restorative

materials for primary molars. Pakistan Oral

& Dental Journal, 35(1), 83-87. Retrieved from https://www.

podj.com.pk/index.php/podj/index

Chisini, L. A., Collares, K., Cademartori, M. G., de Oliveira,

L. J. C., Conde, M. C. M.,Demarco, F. F., & Correa,

M. B. (2018). Restorations in primary teeth: A systematic

review on survival and reasons for failures. International

Journal of Pediatric Dentistry, 28(2), 123-139. https://doi.

org/10.1111/ipd.12346

Cumerlato, C. B. F., Demarco, F. F., Barros, A. J. D., Peres,

M. A., Peres, K. G., Cascaes, A.M.,.. .Corrêa, M. B. (2019).

Reasons for direct restoration failure from childhood to

adolescence: A birth cohort study. Journal of Dentistry, 89,

1-6.https://doi.org/10.1016/j.jdent.2019.103183

Donmez, S. B., Turgut, M. D., Uysal, S., Ozdemir, P., Tekcicek,

M., Zimmerli, B., & Lussi, A. (2016). Randomized

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clinical trial of composite restorations in primary teeth:

Effect of adhesive after three years. BioMed Research International,

1-11. https://doi.org/10.1155/2016/5409392

Dorri, M., Martinez-Zapata, M. J., Walsh, T., Marinho, V.

C. C., Sheiham, A., & Zarror, C.(2017). Atraumatic restorative

treatment versus conventional restorative treatment

for managing dental caries. Cochrane Database of Systematic

Reviews, (12).

https://doi.org/10.1002/14651858.

CD008072.pub2

Firouzmandi, M., Shafiei, F., Jowkar, Z., & Nazemi, F.

(2019). Effect of silver diamine fluoride and proanthocyanidin

on mechanical properties of caries-affected

dentin. Eur J Dent, 13(2), 255-260. https://doi.

org/10.1055/s-0039-1693237

Horst, J. A., Ellenikiotis, H., UCSF Silver Caries Arrest

Committee, Milgrom, P. M. (2016).USCF protocol for caries

arrest using silver diamine fluoride: Rationale, indications,

and consent. Journal of the California Dental Association,

44(1), 16-28. Retrieved from https://www.ncbi.nlm.

nih.gov/pmc/articles/PMC4778976/

Laske, M., Opdam, N. J. M., Bronkhorst, E. M., Braspenning,

J. C. C., & Huysmans, M. C. D. N. J. M. (2019). The

differences between three performance measures on

dental restorations, clinical success, survival and failure: A

matter of perspective. Dental Materials, 35(10), 1506-1513.

https://doi.org/10.1016/j.dental.2019.07.010

Jiang, M., Wong, M. C. M., Chu, C. H., Dai, L., & Lo, E.

C. M. (2019). Effects of restoring SDF-treated and untreated

dentine caries lesions on parental satisfaction

and oral health related quality of life of preschool children.

Journal of Dentistry, 88, 1-7. https://doi.org/10.1016/j.

jdent.2019.07.009

Johhnson, B., Serban, N., Griffin, P. M., & Tomar, S. L.

39

(2019). Projecting the economic impact of silver diamine

fluoride on caries treatment expenditures and outcomes in

young U.S. children. Journal of Public Health Dentistry,

79, 215-221. https://doi.org/10.1111/jphd.12312

Meyer-Lueckel, H., Machiulskiene, V., & Giacaman, R. A.

(2019). How to intervene in the root caries process? Systematic

review and meta-analyses. Caries Research, 53, 599-

608. https://doi.org/10.1159/000501588

Tedesco, T. K., Gimenez, T., Floriano, I., Montagner, A.

F., Camargo, L. B., Calvo, A. F. B., . . .Raggio, D. P. (2018).

Scientific evidence for the management of dentin caries

lesions in

pediatric dentistry: A systematic review and network meta-analysis.

PLoS ONE, 13(11),1-20. https://doi.org/10.1371/

journal.pone.0206296

Vollú, A. L., Rodrigues, G. F., Teixeira, R. V. R., Cruz, L.

R., Massa, G. S., Moreira, J. P. L.,.. .Fonseca-Gonçalves, A.

(2019). Efficacy of 30% silver diamine fluoride compared

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Journal of Dentistry, 88, 1-9. https://doi.org/10.1016/j.

jdent.2019.07.003

40

The Ethics and Effects of Involuntary Treatment

of Mentally Ill People

Anissa Clark

Medical care is one of many fields where consent is

important, but, for some kinds of medical care (i.e. psychiatric

treatment), consent is not always required. It is important

to exam what happens to a mentally ill person due

to involuntary treatment, as well as how they feel about

their own treatment. I would argue that, if the patient does

not consent to treatment, treatment should not be given,

but there is more nuance to this debate than that statement

allows.

Mental illness affects 1 in 5 adults in the United

States (NAMI) and approximately 15.5% of the population

globally (Ritchie & Roser, 2018). That is estimated to be

1.1 billion people (Ritchie & Roser, 2018). These people are

our friends, classmates, and family. If involuntary treatment

as it is done now can lead to suicide and decreased

quality of life then we as a society have a moral obligation

to prevent that. Humans deserve to live comfortable and

happy lives by virtue of being human, and so we must

come together and help those who are not always in a

position to help themselves due to circumstances outside

of their control.

Mental health treatment has a long history of being

involuntary. Many reforms to treatment are recent, such as

the deinstitutionalization movement, which was a movement

in the 1960s that encouraged the release of mentally

ill people from institutions meant to hold them indefinitely

so that they could receive care in their communities and

home (“Treatments for Mental Illness”). However, institutionalization

was not always the solution to mental health

issues in the past (“Treatments for Mental Illness”). Up

until the 8th century, wherein rudimentary asylums were

created by Muslim Arabs, mentally ill people were mostly

allowed to live quiet lives and were taken care of by their

families, but that did not mean they were treated fairly

by society. There were beliefs held that these people were

41

possessed by demons or spirits of some kind (“Treatments

for Mental Illness”). When asylums became established,

fair treatment declined even more. Mentally ill people

were othered along with other “undesirable” people in

society and so were treated inhumanely (“Treatments for

Mental Illness”). In the late 1700s, reforms started being

made in European countries, but one of the first mental

health rights activists, Dorothea Dix, didn’t appear until

the 1800s (“Treatments for Mental Illness”). She ended

up establishing a number of state hospitals in the United

States in order to treat mentally ill patients with a certain

level of care, although conditions remained bad for many

years to come (“Treatments for Mental Illness”). Understanding

of what exactly mental illness is began to appear

around 1883 with German scientist Emil Kraepelin, and

drug therapies, as well as electro-convulsive therapies,

began happening a few decades later (“Treatments for

Mental Illness”). Mentally ill people have been inhumanely

treated for centuries. Their autonomy has been taken

from them due to their mental illness no matter the circumstance.

Involuntary treatment can be inhumane, and

forcing individuals into these treatments can have very

real consequences on their emotional, and physical, wellbeing.

Mentally ill people are commonly thought to be

incapable of making their own decisions and being held

responsible for their own actions. While a lot of people see

this as in favor of mentally ill people, many of those who

have undergone involuntary treatment do not think it is

(Bassman, 2005). First, there is the question of competency.

Competence in terms of commitment, “refers to a person’s

ability to understand and appreciate what is being asked

of them” (Segal, Frasso, & Sisti, 2018, p. 972). Oftentimes

incompetence is assumed unless proven otherwise (Bassman,

2005). This creates a culture where people do not

believe mentally ill people nor do they trust them to make

their own decisions.

The assumption of incompetence of mentally ill

people is caused by stigma. The definition of stigma is,

42

“an individual or a group harboring negative feelings,

attitudes and behaviors toward others who are, typically,

socially constructed in negative ways” (Weiss, Gross,

& Moncrief, 2016, p. 95). Mentally ill people are seen as

automatically a danger to themselves or a danger to others

(Parcesepe & Cabassa, 2012). When a person is perceived

as a danger to themself or others, whether they actually

present a danger or not, people are more likely to view

them as incompetent and more likely to encourage involuntary

treatment (Parcesepe & Cabassa, 2012). Stigma can

be very damaging, not just in that incompetence is assumed,

but it can also hurt mentally ill people’s self perceptions

(Rüsch et al., 2013).

Seclusion and Restraint is one method of involuntary

treatment used in hospitals when patients are seen

as a danger to themselves or others, but is not always

justified in its use (Tochkov & Williams, 2018). A number

of patients, doctors, and nurses participating in a study

done were found to attribute emotional trauma to the

experience of Seclusion and Restraint (Tochkov & Williams,

2018). Involuntary hospitalization has been shown

to cause a lowered self esteem and a worse quality of life,

due to the feelings of powerlessness and loss of efficacy

that it leads to (Tochkov & Williams, 2018). The shame

associated with being coerced into treatment was found

to increase self-stigma, which can also affect quality of life


Involuntary treatment has been linked to suicidality

due to self-stigma (Xu et al., 2018). Of the participants of a

longitudinal study done on the effects of involuntary treatment

and suicidality, 34% reported suicidal ideation at one

year, and 40% reported suicidal ideation at two years (Xu

et al., 2018). Self-stigma and stigma in general have been

found to affect mentally ill people only when they perceive

that they cannot properly cope with the stigmatized

actions being done to them (Rüsch et al., 2013). This means

that when mentally ill people are hospitalized involuntarily

or receive involuntary treatment of any kind, they

have a lack of efficacy in their ability to cope. This lack of

43

efficacy in coping occurs by being put in an environment

where they are powerless and feel out of control. This stigma

stress then causes decreased feelings of empowerment

and more self-stigmatizing views and predicts suicidality


Involuntary treatment also has very real consequences

on the bank accounts of those being treated. A

study found that the average cost of 8.4 days of hospital

treatment for individuals with depression was $6,990

(Stensland, Watson, & Grazier, 2012). 72, 834 people who

participated in the study left the hospital with an average

bill of over $5,000 (Stensland et al., 2012). For those who

are uninsured, that can be a hefty sum of money that will

result in medical bills that can affect credit if not paid off

within a certain amount of time.

Involuntary treatment has an effect on future hospitalizations

as well (Jaeger et al., 2013). Patients who

have been involuntarily hospitalized are more sensitive to

coercive treatment and so report that they are more inconsistent

with keeping up with their treatment (Jaeger et al.,

2013). The reported lack of consistent treatment can cause

them to be hospitalized multiple times, and, since they are

sensitive to involuntary treatment already, start the cycle

of sensitivity over again. (Jaeger et al., 2013). It is all in

how the patient views their own treatment. (Priebe et al.,

2009). A study found that, “Patients who express a lower

satisfaction with hospital care within the first week of

involuntary admission are more likely to be involuntarily

readmitted within 1 year” (Priebe et al., 2009, p. 51). This

means that, if a patient believes they are being coerced

or that the treatment is not satisfactorily helping them

enough to justify the violation of rights that took place,

they will not get better.

A counter argument could be made that involuntary

treatment in all situations is necessary and that the

good outweighs the potential effects. I think that, even in

situations where involuntary treatment is used to save a

person’s life, these effects can be mitigated with a system

better equipped to empower mentally ill people. It is not

44

the institution of involuntary treatment that is at fault but

the system of which involuntary treatment is a tool of. If

we adjust the system and make it better equipped to handle

mentally ill individuals as people rather than as dangers

that cannot think for themselves then we can create a

more productive environment for recovery.

A proposed solution to the problems of the system

is better education. Education here refers to many different

kinds. Education in terms of amount of schooling for

doctors and nurses was linked to less ethical violations

in psychiatric nurses (Eren, 2013). There are people that

are incapable of making decisions about their treatment

and are a danger to themselves or others that need to be

assessed by professionals, but these assessments are often

made with a bias (Tochkov & Williams, 2018). Better

education on mental disorders and ethical practices could

work to remove that bias because it would allow for more

knowledge of what is required of professionals in this

working environment and inform them more of the violations

that are possible when working with mentally ill

individuals. Education is not just limited to those in the

system such as judges, doctors, and nurses. Patients also

need to be informed of their treatment. Many patients

report feeling out of control in their treatment (Tochkov &

Williams, 2018). In a study done on what patients value in

treatment when it is involuntary, one man reported, “All

your rights are taken away, it’s horrible, you are not in

control anymore” (Valenti, Giacco, Katasakou, & Priebe,

2013, p. 833). Keeping patients informed of the things happening

in their treatment and receiving feedback and actually

applying it could help patients feel less out of control

and allow them to develop positive feelings towards their

treatment. If patients feel that they have power over their

treatment process, even if they were not initially planning

to go to the hospital, it can lead to greater feelings of efficacy,

less self-stigma, and suicidality that self-stigma can

cause (Rüsch et al., 2013).

There is one more meaning of education in this

case: education of the public to prevent stigma. “Education

45

was negatively associated with dangerousness with higher

levels of education related to perceiving people with

mental illness as less dangerous to themselves and others”

(Parcesepe & Cabassa, 2012, p. 389). An education-based

campaign was found to reduce stigma in college students

(Kosyluk et al., 2016). Education was also found to work

better as an anti-stigma intervention tool when coupled

with contact (Dalky, 2011). Contact refers to interpersonal

contact (Kosyluk et al., 2016). When education and contact

are used together in a program, it has been shown to lead

to statistically significant improvement in college students

stigmatizing beliefs and actions (Dalky, 2011). Less stigma

means that mentally ill people are less likely to be automatically

perceived as dangerous or incompetent, which

will then help to influence the decision to placed mentally

ill peers in involuntary care.

The purpose of this essay is not to do away with

treatment altogether, but to create a better environment

for treatment to be possible. Hospitalization as we do it

now can create a damaging environment for mentally ill

individuals, but deinstitutionalization led to upset in the

mental health community due to the homelessness problem

that occurred when there was no follow up treatment

once mentally ill people were taken out of the hospital

system (“Treatment of Mental Illness”). I propose that

we as a society should put less of a focus on immediate

care and more focus on consistent care. This means introducing

community-based treatment plans for mentally

ill individuals, such as therapy groups, as opposed to a

hospital environment where care can last for an indeterminate

amount of time and information is not shared with

the patients. This could increase efficacy, thus reducing

self-stigma as well as create a program that continuously

follows up with patients in order to ensure their recovery.

Individuals who had community-based treatment plans as

opposed to the dehumanization that can come with being

hospitalized reported a better quality of life (Hobbs, Newton,

Tennant, Rosen, & Tribe, 2002). This means that they

were better functioning and in a better place financially,

46

emotionally, and physically than their counterparts who

did not receive a community-based treatment plan. Community-based

treatment could also help to get mentally ill

individuals a consistent job. A study done on the readmission

of mentally ill people after one year and their views

of treatment proposed that, “The association of being on

welfare benefits with higher readmission rates may underline

the importance of social inclusion programmes…”

(Priebe et al., 2009, p. 53). These social inclusion programmes

can work to put mentally ill individuals into the

workforce and allow them a better quality of life. Not only

that, but better follow up and treatment plans can prevent

as many mentally ill people from being incarcerated. According

to a study done on the treatment of prisoners with

mental illnesses, “Approximately 20% of the roughly 2.5

million individuals incarcerated in the United States have

a serious mental illness” (Segal et al., 2018, p. 963). If care

were more consistent, prisons would not have to act as

treatment facilities for the mentally ill. Mentally ill people

would find treatment outside of a prison environment.

In conclusion, mentally ill people have been involuntarily

treated for centuries and that treatment has very

real consequences on the way mentally ill people view

themselves and their relationship with society. This can

lead to suicide or decreased quality of life. These problems

are systemic in nature and the best ways to address them

are better education for the general public, those working

in mental health related fields, and the community as a

whole, as well as better community-based programs that

encourage social skills and functioning well enough to

hold a job in order to provide consistent care for individuals

who have problems existing in society due to their

mental illnesses. This can all lead to the betterment of

mentally ill people which will also help society as a whole

because, as much as stigma will tell us otherwise, mentally

ill people are a part of our society and they should be

treated with the respect and dignity that is afforded to all

humans.

47

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Dalky, H. F. (2011). Mental Illness Stigma Reduction Interventions.

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doi:10.1177/0193945911400638

Eren, N. (2013). Nurses’ attitudes toward ethical issues in

psychiatric inpatient settings. Nursing Ethics,21(3), 359-373.

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(2002). Deinstitutionalization for Long-Term Mental Illness:

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Psychiatry,36(1), 60-66. doi:10.1046/j.1440-1614.2002.00984.x

Jaeger, S., Pfiffner, C., Weiser, P., Längle, G., Croissant,

D., Schepp, W., . . . Steinert, T. (2013). Long-term effects

of involuntary hospitalization on medication adherence,

treatment engagement and perception of coercion. Social

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doi:10.1007/s00127-013-0687-x

Kosyluk, K. A., Al-Khouja, M., Bink, A., Buchholz, B.,

Ellefson, S., Fokuo, K., . . . Corrigan, P. W. (2016). Challenging

the Stigma of Mental Illness Among College

Students. Journal of Adolescent Health,59(3), 325-331.

doi:10.1016/j.jadohealth.2016.05.005

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Parcesepe, A. M., & Cabassa, L. J. (2012). Public Stigma of

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Review. Administration and Policy in Mental Health and

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Mental Health Services Research,40(5), 384-399. doi:10.1007/

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Priebe, S., Katsakou, C., Amos, T., Leese, M., Morriss, R.,

Rose, D., . . . Yeeles, K. (2009). Patients views and readmissions

1 year after involuntary hospitalisation. British

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bp.108.052266

Ritchie, H., & Roser, M. (2018, January 20). Mental Health.

Retrieved from https://ourworldindata.org/mental-health

Rüsch, N., Müller, M., Lay, B., Corrigan, P. W., Zahn, R.,

Schönenberger, T., . . . Rössler, W. (2013). Emotional reactions

to involuntary psychiatric hospitalization and stigma-related

stress among people with mental illness. European

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35-43. doi:10.1007/s00406-013-0412-5

Segal, A. G., Frasso, R., & Sisti, D. A. (2018). County Jail or

Psychiatric Hospital? Ethical Challenges in Correctional

Mental Health Care. Qualitative Health Research,28(6), 963-

976. doi:10.1177/1049732318762370

Stensland, M., Watson, P. R., & Grazier, K. L. (2012). An

Examination of Costs, Charges, and Payments for Inpatient

Psychiatric Treatment in Community Hospitals.

Psychiatric

Services,63(7), 666-671. doi:10.1176/appi.ps.201100402

Tochkov, K., & Williams, N. (2018). Patient or Prisoner?

Forced Treatment for the Severely Mentally Ill: Life-Long

Implications for Patients Who Have Been Treated Against

Their Will. Ethical Human Psychology and Psychiatry,20(1),

56-68. doi:10.1891/1559-4343.20.1.56

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nash-treatments-mental-illness/

49

Valenti, E., Giacco, D., Katasakou, C., & Priebe, S. (2013).

Which values are important for patients during involuntary

treatment? A qualitative study with psychiatric inpatients.

Journal of Medical Ethics,40(12), 832-836. doi:10.1136/medethics-2011-100370

Weiss, E. L., Gross, G. D., & Moncrief, D. (2016). Can

Health Care Reform End Stigma Toward Mental Illness?

Journal of Progressive Human Services,27(2), 95-110. doi:10.10

80/10428232.2016.1155249

Xu, Z., Müller, M., Lay, B., Oexle, N., Drack, T., Bleiker,

M., . . . Rüsch, N. (2018). Involuntary hospitalization,

stigma stress and suicidality: A longitudinal study. Social

Psychiatry and

Psychiatric Epidemiology,53(3), 309-312. doi:10.1007/s00127-

018-1489-y

50

A Call for American Sentencing Reform

Amanda Greenwood

Mass incarceration refers to the ever-increasing

prison population in the United States, being the root

cause of harms in the status quo and an effect of the

subsistence of an overtly inadequate and discriminate

sentencing system. Offenders are overly criminalized,

sometimes when they still are even awaiting trial and thus

presumed innocent, and more so upon the completion

of their sentences when they are then further ostracized

by society due to a lack of rehabilitation. Aside from this,

there is a disproportionate number of incarcerated offenders

from minority groups because of a disparity in

sentencing based upon judge discretion, in addition to

inherently racist and classist sentencing procedures. Thus,

in order to curb the continuation of mass incarceration, it

is necessary to reform the American sentencing system.

As a means to conduct this analysis it is first pertinent

to establish the harms correlated with the perpetuation

of mass incarceration and the causational relationship

the current sentencing system has upon its subsistence.

The high congestion of incarcerated peoples coinciding

with lengthy prison terms were primarily supported as

a means to deter crime; however, in actual practice it is

obvious that mass incarceration has not had its presumed

positive impact upon the criminal justice system. The

clearest evidence of this is the fact that “American crime

rates have declined substantially and continuously since

1991 . . . but the imprisonment rate, including local jails,

rose for the following quarter century” (Tonry 442). These

logistics not only identify the ineffectiveness of mass incarceration

in addressing crime, but go on to showcase the

fact that offenders are being incarcerated longer for lesser

crimes under the current sentencing system. Apart from

the illogical implementation of mass incarceration due to

a statistically proven lack of intended effects, this subsistence

has incalculable harms upon offenders and, blatantly,

society itself. “Imprisonment reduces future earnings

51

and job opportunities, limits civic participation, contributes

to mental and physical health problems, destabilizes

families, and further disadvantages economically marginalized

communities” (Copp and Bales 104). As can be seen,

mass incarceration results in a nearly inevitable detriment

to each individual offender and their dependents, in addition

to the marginalized communities in which they may

be a part of. Any hope for reforming the current American

sentencing system rests within an ideological shift

from viewing offenders as inherently criminal to viewing

them as innately human. There are moral repercussions in

allowing the subsistence of an unjust sentencing system in

the United States, as they undermine any value of justice

or equal opportunity that a democracy is intrinsically

poised to represent.

One of the stark malpractices concerning the American

sentencing system is the disproportionate number of

incarcerated offenders from minority groups and low-income

financial thresholds. There are institutionalized practices

within the court system that further this existence,

such as pretrial incarceration. To ensure defendants will

appear for their court date, monetary bail has become the

primary pretrial release mechanism in courts within the

United States, epitomized by the fact that at “the end of

2015, more than two thirds (63 percent) of all jail inmates

were awaiting trial (and thus legally presumed innocent)”

(Copp and Bales 113). This directly leads to the continuation

of mass incarceration given that if an individual is not

financially capable of paying the set bail amount, they are

subsequently incarcerated. This is even more important

given that the cycle of poverty often occurs within environments

that are entrenched in crime. Thus, monetary

bail obliterates equitable opportunity to escape the aforementioned

cycle since even impoverished individuals

who are accused, but not yet determined as guilty, face

the same treatment as if they were already charged with a

crime. Apart from institutionalized court practices which

directly relate to sentencing, there are also inherently

discriminatory sentencing laws. This is most clearly seen

52

in the disparity between crack cocaine and powder cocaine

offenses. A disposition has developed towards crack

cocaine for being known as the drug of choice among

minority groups, whereas powder cocaine is often viewed

as the “White man’s drug” (Chappell and Maggard 276).

This stereotyping correlates to the fact that “those arrested

for crack cocaine are significantly more likely to be

charged with a felony and sent to prison versus being released,

compared to powder cocaine offenders” (Chappell

and Maggard 276). It is important to note that there is no

difference in the drug itself other than its physical appearance,

thus prejudice is seen to take hold in place of justice

within these sentencing terms.

Other than these institutionalized harms within the

American sentencing system, the arbitrary decision-making

conducted by judges is another key site for sentencing

reform. Not only has court clogging led to a decrease in

analysis of the circumstances surrounding specific cases,

but judges engage in discrimination when determining

their imposed sentences. As a means to accelerate the

amount of cases they can hear and to avoid backlash from

the public, judges often do not analyze each case as independent

of another and instead look towards precedents

set by previous decisions to determine sentences in current

cases (Robinson 5). This results in a continuation of

improper sentencing imposed upon offenders, for there

is no evaluation of the adequacy of former sentences or

the consideration of unique circumstances surrounding

particular cases. In these instances, the lack of judge engagement

is the root of unjust sentences; however, arbitrary

judge discretion can as well lead to discriminatory

sentencing. Sentencing guidelines prohibit race, sex, or

national origin as being factors involved in sentencing

decisions, but studies of sentencing disparities found an

unexplainable imbalance disfavoring men, African Americans,

and Hispanics (Schanzenbach 62). One could equate

this evidence to support an overarching maintenance of

prejudice, but implicit discrimination is not always the

case; sometimes “judges are engaged in ’rational discrimi-

53

nation’ against minorities and men because they perceive

men and minorities to be more dangerous and more likely

to recidivate” (Schanzenbach 63). Although, if “rational

discrimination” is a possibility, it seems obvious that bias

must already be present against certain groups of people

in the determination of sentencing. This is a direct reason

for why part of this critical sentencing reform needs to be

aimed at judges and their culpability in sustaining mass

incarceration.

Sentencing practices concerning nonviolent drug

offenders are at the forefront of requiring reform, such as

the abolishment of jury trials for marijuana possession.

In order to contextualize the harms associated with such

an implementation it is necessary to identify the confliction

concerning marijuana decriminalization across state

lines. Some states have already legalized both the medical

and recreational use of marijuana, and others are making

progressive movements towards its decriminalization,

as now “Massachusetts treats possession of one ounce or

less of marijuana as a civil offense similar to a traffic citation”

(Whitten 920). However, other states are considering

increasing their penalties for marijuana possession and

maintain much harsher punishments within the status

quo, as seen in the fact that “one ounce of marijuana in

Florida carries a maximum penalty of five years imprisonment

and a fine of $6,000” (Whitten 920). In an attempt

to minimize the penalty attached to marijuana possession,

some states, like Maryland, maintain the causational harm

of subjecting offenders to bench trials. However, a jury not

only provides an integral check upon the judicial branch

of government, but “the right to a trial by jury in a criminal

case is arguably America’s oldest and most treasured

right” (Whitten 921). The implementation of bench trials in

nonviolent drug cases such as these leads to the violation

of values that the United States Criminal Justice system

was founded to protect. In addition to this, “a bench trial

gives prosecutors a greater chance at conviction” (Whitten

924). Thus, not only are the inherent rights of offenders

being violated, but these bench trials are exacerbating the

54

propensity towards mass incarceration. In the context of

the previously depicted inadequacy of judges in the determination

of sentencing, this right to a jury pushes itself to

the forefront of importance.

Mandatory minimum sentences have an extreme

effect on those even minimally involved in drug crimes.

Specifically, women who become involved in drug trafficking

due to romantic or familial relationships with male

drug traffickers are a vulnerable population for systemic

injustice. “Drug-related crimes account for 24% of women

in state prisons and are the most common conviction

(58.8%) for women in federal prison, primarily drug trafficking

charges” (Willison and O’brien 39). Federal conspiracy

laws allow these women to be subjected to harsher

sentences with minimal participation in the crimes committed.

The issue here is that the commitment of the crime

is often intrinsically intertwined with an emotional attachment

to the main offender, but under conspiracy laws the

context of such a relationship is completely ignored (Gaskins

1533). In the case of mandatory minimum sentencing,

judges are not able to evaluate the “mitigating factors that

would normally reduce sentences for less culpable offenders

under the Federal Sentencing Guidelines’ system

of calculating offenses” (Gaskins 1533). This occurrence

is a contributing factor to the extreme increase of women

within the incarcerated population and can be contextualized

as a much broader symptom of oppressive patriarchal

social structures embedded within this system of imposed

power.

Through this in-depth analysis of various current

procedures within the American sentencing system, the

necessity for reform has become readily apparent. Not

only are there clearly institutionalized practices that are

inadequate in properly serving justice, but these, in accompaniment

with biased judge discretion, disproportionately

target individuals from marginalized communities

and serve as the foundation for the maintenance of mass

incarceration. Attempts to combat this existence on a dayto-day

basis are mostly coordinated by the collaboration of

55

social workers and defense lawyers to provide alternatives

to incarceration. Written mitigation is a key site for this

enactment, which details a defendant’s personal life and

relevant history to “humanize the client so judges can see

the human being beyond the alleged crime” (Nnenna et al.

39). It has been proven that there is a positive correlation

between written mitigation and better sentences. However,

the fact that it has been necessary to “humanize” offenders

provides evidence for why an ideological shift in

the perception of crime and those accused of it is a necessary

precondition for reform.

Minimal reform has thus far been accomplished

through U.S. Supreme Court cases, such as Brown v. Plata,

as well as at the state level to aid the mitigation of incarceration

(Tonry 443). These previous rulings have simply

addressed individual instances of overcrowding, but not

the root cause for the existence of mass incarceration. In

addition, my research has identified a clear inadequacy

within individual judge determinations of sentencing,

but not any mandates to rectify their imposed harms.

However, in recent presidencies there has been proposed

executive action in an effort to address certain root causes

of mass incarceration. The most prominent reform implementation

during the Obama administration was the

reversal of a policy in which prosecutors were required

to bring charges aiming for the most severe sentences

(Obama 811). This has allowed for more focus on serious

cases and serious offenders, as opposed to minor offenses

that are a central location for mandatory minimum sentencing.

This directly targets one of the hot-spots aiding

mass incarceration; however, one policy alteration is not

satisfactory for further reversal of mass incarceration and

prison reform. Passing a bill through Congress would

actually provide federal legislation for sentencing reform,

such as the Sentencing Reform and Corrections Act proposed

in 2015, which “would have reduced mandatory

minimum prison sentences for thousands of nonviolent

drug offenders” (Obama 811). However, the issue here

that has thus far prevented such expansive implementa-

56

tions is the existence of increasingly polarized political

representation at the federal level. This is a pertinent

problem given that the Smart on Crime initiative aiming to

assist low-level non-violent offenses and vulnerable populations

has been supported across party lines (Mcmillion

65).

There is, of course, a counterargument to reforming

the sentencing system, being that alterations within

sentencing practices will not change the current outcomes

within the status quo. Research has been conducted over

Ohio trial courts where there was an implemented shift

from indeterminate sentencing to determinate sentencing.

It was found that a switch to determinate sentencing did

not decrease the disproportionate number of serious sentences

upon racial minorities, such as African Americans,

as opposed to their white counterparts (Wooldredge et al.

850). This research provides evidence of a negative outcome

due to sentencing reform. However, I would argue

that this proposed reform found such results due to the

fact that overt judge discretion is a harm within itself. Instead,

the sentencing system needs a standard of rationality

where every decision made by judges “should be able

to explain, in a systemic way, why the sentence selected

in a case is preferable to the sentences not selected” (Robinson

5). In addition, the methodology of this study solely

relied on the use of judges in the decision-making process,

which provides further evidence of why bench trials

should be eliminated if judges are the ones exacerbating

this unequal sentencing upon defendants.

In summation, mass incarceration is an epidemic

that is ill-practiced for crime prevention and provides

innumerable harms upon the criminal justice system.

Individuals are not guaranteed equal punishment for their

accused crimes and this has been empirically proven to

disproportionately affect minority groups. Furthermore,

this subsistence systemically undermines the values that

our democracy is intrinsically poised to protect and uphold.

The only way to curb mass incarceration is by attacking

its root cause, the American sentencing system. There

57

is a plethora of holes allowing for an inadequate process of

justice, but bipartisan support is the needed path towards

effective reform. Federal initiatives dictating the abolishment

of bench trials and the reduction of mandatory minimum

sentences for nonviolent drug offenders should be

the primary focus of such reform, as these directly affect

the deconstruction of mass incarceration. Although there

has been proposed evidence that sentencing reform has no

significant effects upon the status quo, this solely relied on

judge discretion that has already been proven as requiring

reform. In addition, proposing change is the only solution

to rectifying harms in our present world, as doing nothing

ensures the perpetuation of the negative impacts that have

been descripted throughout this analysis. Thus, the only

possible achievement of solvency and the reduction of the

immense harms that we have allowed to remain intact is

through enacting sentencing reform.

Works Cited

Copp, Jennifer E., and William D. Bales. “Jails and Local

Justice System Reform: Overview and Recommendations.”

The Future of Children, vol. 28, no. 1, 2018, pp. 103–124.

Chappell, Allison T., and Scott R. Maggard. “Applying

Black’s Theory of Law to Crack and Cocaine Dispositions.”

International Journal of Offender Therapy and Comparative

Criminology, vol. 51, no. 3, June 2007, pp. 264–278.

Gaskins, Shimica. “‘Women of Circumstance’--the Effects

of Mandatory Minimum Sentencing on Women Minimally

Involved in Drug Crimes.” American Criminal Law Review,

vol. 41, no. 4, 2004, p. 1533.

Mcmillion, Rhonda. “Getting Smarter on Sentencing:

Bipartisan Push Is on for This Criminal Justice Reform.”

ABA Journal, vol. 100, no. 2, 2014, p. 65.

Nnenna Onyema, et al. “Evaluating the Success of Written

Mitigation in Reducing Prison Sentences and Achieving

58

Alternatives to Incarceration for Parole Violations.” Columbia

Social Work Review, 2017, pp. 35–49.

Obama, Barack. “The President’s Role in Advancing Criminal

Justice Reform.” Harvard Law Review, vol. 130, no. 3,

2017, p. 811.

Robinson, Paul. “One Perspective on Sentencing Reform in

the United States.” Criminal Law Forum, vol. 8, no. 1, 1997,

pp. 1–41.

Schanzenbach, Max. “Racial and Sex Disparities in Prison

Sentences: The Effect of DistrictLevel Judicial Demographics.”

The Journal of Legal Studies, vol. 34, no. 1, 2005, pp.

57–92.

Tonry, Michael. “Making American Sentencing Just, Humane,

and Effective.” Crime and Justice, vol. 46, no. 1, 2017,

pp. 441–504.

Willison, Judith S, and Patricia O’brien. “A Feminist Call

for Transforming the Criminal Justice System.” Affilia, vol.

32, no. 1, 2017, pp. 37–49.

Whitten, Taylor E. “Under the Guise of Reform: How Marijuana

Possession Is Exposing the Flaws in the Criminal

Justice System’s Guarantee of a Right to a Jury Trial.” Iowa

Law Review, vol. 99, no. 2, 2014, pp. 919–955.

59

Child Abuse in Texas

Eve N. Miller

Abstract

According to “Domestic Violence Advocacy Two” by Jill

M. Davies and Eleanor Lyon, the environment and care

that children need for healthy development can be destroyed

by family violence. Family violence is an umbrella

term that covers domestic violence, intimate partner

violence, elder abuse, domestic abuse, and child abuse.

Sexual assault can include rape, attempted rape, sexual

coercion, incest, fondling, any sexual act without consent,

voyeurism, exhibitionism, and sexual harassment (Davies

et al., 2014). While the definitions do not necessarily seem

to go hand in hand, those that experience domestic violence

usually experience sexual assault and vice versa. Not

to mention that they often have the same effects; severe

injuries, impaired brain development, and bad coping

mechanisms, among many others.

Child Abuse

While children are often just as involved in domestic

violence cases, they are not necessarily the focus of the

issue. There are some studies that follow children through

the aftermath of violence that they witness but they are

often just a second thought, especially when it comes to

advocacy (Davies et al., 2014). Though a violent person in

the household disrupts a child’s sense of security. Because

they do not have the knowledge, they are left to try and

manage their conflicting feelings of fear and anger without

the autonomy of an adult.

Statistics and Effects of Family Violence and Sexual Assault

Statistically, more than 15 million children in the

U.S. experience childhood domestic violence, while 1 in

5 girls and 1 in 20 boys have been victims of child sexual

abuse (Child Abuse Statistics, n.d.; Effects of Domestic

Violence, n.d). Early studies found that physical abuse

of children in homes where the partner abuse occurred

60

ranged from 40 percent to 75 percent, and a study of child

protection records found indications of domestic violence

in an average of 48 percent of them (Davies et al, 2014).

Though these studies do not take into account the 20 percent

of a large national sample of children who have witnessed

violence in their home along with 16 percent who

had seen parental violence (6 percent within the last year),

one study of 5,000 reported incidents of domestic violence

found that children were present at the time in about 44

percent of the cases (Davies et al, 2014).

When it comes to the effects of family or domestic

violence, children can often suffer from anxiety, depression,

and traumatic stress, as well as difficulty in relationships.

Women who had been exposed to parental violence

in childhood experienced more distress and lower social

adjustment as adults compared to those that had not been

exposed (Davies et al, 2014). Children that have suffered

from sexual abuse can develop feelings of low self-esteem

and worthlessness, along with a distorted view of sex

(Child Abuse, n.d.). While the numbers are staggering

with more than fifteen million kids witnessing family violence

each year, only about 30 percent of children continue

the cycle of abuse (Child Abuse Statistics, n.d.). Though

the children are more likely to engage in “sexual risk-taking

behavior” and teen pregnancy later on in life (Child

Abuse Statistics, n.d.). There is even a more likely chance

of a child to be abused (resulting in these affects) when

there is battering violence, as well as there being more

children in the home. There are also psychological problems

that often manifest as high-risk behaviors that can

include smoking, using drugs, and even overeating, which

can lead to long-term problems, though not all children

face these issues (Child Abuse, n.d.).

Studies also show that while mothers sometimes

abuse their children, it typically occurs at lower rates than

when men do (Davies et al., 2014). Though about 30 percent

of women who had been abused reported that they

had used “harsh punishment” on their children due to the

stress of the abuse (Davies et al., 2014). Some abuse may

61

also occur after a mother tries to protect her kids from an

abusive partner (about 35 percent of the time), related to

how violence affects parenting (Davies et al., 2014).

Many factors go into the research of domestic violence

(exposure, resources, experience, number of children

in the family, gender, race/ethnicity, culture), which

should be “measured and disentangled” to determine the

impact of exposure, all which help determine the impact

(which is likely to vary over time). Those who had experienced

parental violence and “power assertive” punishment

in childhood experienced more “maladjustment” in

adolescence, whereas women who had reported that they

had been exposed to family violence in childhood were more

likely to experience depression and low self-esteem among many

others (Davies et al, 2014).

Comparison between Family Violence and Sexual Assault.

While not all statistics focus on children, there is

still the relationship between family/domestic violence

and sexual assault. Research shows that between 40 percent

and 45 percent of women in abusive relationships

also experience sexual assault during the relationship,

along with suffering severe and long lasting physical and

mental health problems. Studies have also found people

who had “adverse childhood experiences” had physical

and emotional problems (the more ACE’s, the more problems)

(Davies et al., 2014).

Some of the same risk factors make children more

susceptible to violence such as; poverty, lack of bonding

between parent and children, mental health problems, and

many others. They also have some of the same side effects

that come after the witnessing and experience; pregnancy,

PTSD, anxiety, risky behaviors, etc.

Though, while they have all of these things in

common, and are often related, there are some differences.

While violence is almost always perpetrated by someone

the victims knows, sexual assault only occurs by someone

the victims knows about 80 percent of the time. Domestic

62

violence is also more of a pattern of abuse, whereas sexual

assault is using sex as a weapon.

With all of these similarities one cannot forget a

glaring issue, children who have suffered from either type

of abuse have a tendency to re-enact and recreate their

victimization on others, they repeat and perpetrate an “aggressor-victim”

interaction with subsequent relationships

(Green, 1988). Although there are differences in the impact

of violence against children, when it comes to sexual

abuse, children are more likely to have sexual behavior

and knowledge that is inappropriate for the child’s age as

well as inappropriate sexual contact with another child,

having a sexually transmitted infection, and many others

(Child Sexual Abuse, 2017).

Whereas when it comes to children who have been

physically abused, they often have unexplained injuries,

such as bruises, fractures, and burns, and their explanations

usually do not match, along with the symptoms that

go along with emotional abuse (delayed emotional development,

low self-esteem, depression) (Child Abuse, n.d.).

In addition, men who had been exposed to physical and

sexual abuse, as well as parental violence, were four times

more likely to have engaged in domestic violence as an

adult (Davies et al, 2014).

Though some reviews have reported that exposed

and non-exposed children generally had the same scores

on measures of emotional health, 37 percent of kids who

had been exposed were doing as well as those who had

not been exposed (Davies et al, 2014). Though there were

more emotional and behavioral effects among children

who had experienced physical abuse and exposure than

kids who were just “exposed” (Davies et al, 2014).

Studies for each type of violence with a comparison to

Texas.

In Texas, more than three children die from abuse

or neglect on average every week, with more than one

hundred and eighty-two children confirmed as victims

daily, and more than seven children being maltreated

63

every hour (What is Child Abuse, n.d.). Though, besides

statistics there is not a lot of information to find on family

violence and children in Texas.

Some of the only information that is easily accessible is a

study from CWLA, Texas’s Children 2018, though it covered

child abuse and neglect (and not necessarily family

violence) from 2016 to 2015. From the 237,533 total referrals

for child abuse in 2016, only 186,024 were referred for

investigation, with 217 reported child deaths as a result of

abuse or neglect (Texas’s Children 2018, n.d.). According

to the National Coalition Against Domestic Violence, one

in five children are exposed to intimate partner violence

each year, and ninety percent of those children are eyewitnesses

to the violence.

In a study from 2018 there is said to be 175 children

in Texas who will be victims of abuse, with 98 percent

knowing their alleged abuser and 21 percent not even

being old enough to attend kindergarten (Child Abuse in

Texas, n.d.). In a study from The Children’s Assessment

Center in Houston Texas, the true prevalence of sexual

abuse is not known according to adult retrospective studies,

1 in 4 women and 1 in 6 men were sexually abused

(which means that there are more than 42 million adult

survivors of sexual abuse in the United States).

What can be changed in field work and practice.

When it comes to things like Child Protective Service

investigations, the social workers have a tendency to

act before they have all of the necessary information. They

take the vague information or concern that they have and

open a case against a parent, even though it is not usually

about the parent that has caused the case to be open. It

seems like CPS does want to help the children involved in

the cases, but they just do not go about it in the right way.

According to “Stop Violence Against Women,” instead

of taking action to have perpetrators removed from

the home and holding them accountable, CPS makes the

mistake of alleging neglect by the victim and removing

the children from their custody. And when victims do not

64

take action to remove the abuser from the home, it is used

against them during court proceedings though, this occurs

even when victims trying to have the perpetrator removed

(Child Protective Services and Domestic Violence, n.d.).

While things have changed since women first had

access to shelters that protected them from abusive partners,

we are now at a time where we are holding women

to impossibly high standards (Brickman, n.d.). The Vera

Institute of Justice writes that women often do not feel

comfortable talking about the abuse that they and their

children have faced, and when they do speak up it is often

in an effort to make sure that the abuser does not have

more access to hurt the children, which some judges take

as alienation. It does not really make sense why a judge

would take the side of an abuser though, that is exactly

how a battered mother loses custody of her children.

While some people still advocate the use of protective

orders, they are not necessarily beneficial. They do

not always include the children and can be used by CPS

to open a case against them. Though, because protective

orders are a step above a restraining order, when abusers

violate them, they are punished by getting jail time. While

this does not necessarily directly affect the children in the

home, it puts them at an even greater risk.

If we, social workers, do not go through each fact

and really look at each situation then we will never make

the best decision for the victims. You cannot blame the

victim for being abused, and you cannot blame one victim

for not saving another. Most battered mothers make an

effort to protect their children from the same harm they

endure, it is just harder than most think. But if we changed

the way that CPS looks into cases and the way prosecution

takes place, it may take away some of the stigma of

making a complaint or a report, and victims may become

willing and truthful.

References

By:, S. (n.d.). Child Abuse in Texas. Retrieved March, 2019,

from https://www.cactx.org/child-Abuse-in-texas

65

Child abuse. (2018, October 05). Retrieved February, 2019,

from https://www.mayoclinic.org /diseases-conditions/

child-abuse/symptoms-causes/syc-20370864

Child sexual abuse. (2017). Retrieved March, 2019, from

https://www.who.int/violence_injury _prevention/resources/publications/en/guidelines_chap7.pdf

Child Abuse Statistics. (n.d.). Retrieved February, 2019,

from https://americanspcc.org/child- abuse-statistics/

Child Abuse Statistics. (n.d.). Retrieved February,

2019, from http://victimsofcrime.org/media/ reporting-on-child-sexual-abuse/child-sexual-abuse-statistics

Child Protective Services and Domestic Violence. (n.d.).

Retrieved February, 2019, from http://www.stopvaw.org/

domestic_violence_child_protective_services

Davies, J., Lyon, E., & Davies, J. (2014). Domestic violence

advocacy: complex lives/difficult choices. Thousand Oaks,

CA: SAGE.

Domestic Violence: Orders of Protection and Restraining

Orders. (n.d.). Retrieved February, 2019, from https://family.findlaw.com/domestic-violence/domestic-violence-orders-of-

protection-and-restraining-orders.html

Effects of domestic violence on children. (2019, April 02).

Retrieved March, 2019, from https://www.womenshealth.

gov/relationships-and-safety/domestic-violence/effects-domestic-

violence-children

Facts & Data - TexProtects: The Texas Association for the

Protection of Children. (2019, April 20). Retrieved March,

2019, from https://www.texprotects.org/CANfacts/

Green, A. H. (1988, December). Child maltreatment and

66

its victims. A comparison of physical and sexual abuse.

Retrieved February, 2019, from https://www.ncbi.nlm.nih.

gov/ pubmed/3062593

NCADV | National Coalition Against Domestic Violence.

(n.d.). Retrieved March, 2019, from

https://ncadv.org/blog/posts/quick-guide-domestic-violence-and-sexual-abuse

The Differences Between Sexual Violence and Domestic

Violence. (n.d.). Retrieved March, 2019, from https://blog.

sapars.org/the-differences-between-sexual-violence-domestic

-violence/

Victims of Domestic Violence Need Greater System Support.

(2016, December 20). Retrieved February, 2019,

from https://www.vera.org/blog/victims-of-domestic-violence-need

-greater-system-support

Violence against children. (2018, February 06). Retrieved

March, 2019, from https://www .who.int/mediacentre/factsheets/violence-against-children/en/

67

The Effect of Music Therapy Combined with

Equine-Assisted Activities on Physical and Communication

Skills of a Woman with Stroke-Induced

Quadriplegia: A Pilot Case Study.

Heather Mock

Abstract

This paper explores the process and results of a pilot collaboration

of music therapy and equine-assisted activities

for a woman with stroke-induced quadriplegia. Over a

three month period, music therapy interventions were implemented

during the rider’s riding lessons. The researcher

maintained fieldnotes in addition to administering

feedback surveys to those involved at the riding center.

Interventions included but were not limited to redirection,

riding posture reminders, task analysis songs, and music

and movement. This treatment combination appeared to

increase participant motivation, expressive communication

skills, and motor skills. Additional research is needed

in this type of treatment combination.

Introduction

Cerebral Hemorrhages

People of varying age and health may experience a

stroke of any kind during their lifetime. According to the

National Stroke Association, “stroke is the leading cause of

adult disability in the U.S.” (2019). There are two categories

of strokes: ischemic and hemorrhagic. A hemorrhagic

stroke occurs when a blood vessel in the brain bursts and

blood leaks into the brain, causing brain cell damage and

death (NINDS, 2019). An ischemic stroke occurs when

blood flow is blocked in the brain. Because strokes originate

in the brain, many areas of functioning are hindered

or lost after a stroke: cognition, communication, mobility,

and emotional affect. Common physical consequences of

stroke include forms of paralysis. Treatment for those who

have experienced a stroke may include pharmaceuticals,

physiological therapies, speech therapy, and counseling.

Equestrian-Assisted Activities and Therapy

68

Equine-assisted activities and therapies (EAAT)

involve therapeutic riding lessons, horse grooming, stable

management, riding competitions, and any other activities

that may occur at an equestrian center (PATH, 2018). These

activities mainly involve the rider/client, horses, riding

instructors, or center volunteers. Goals addressed through

EAAT include improving the cognitive, physical, emotional

and social abilities of riders – specifically in fields

of health, education, sport, and recreation. EAAT treats a

wide variety of populations in age and ability. However,

according to data collected in 2017, approximately half

of the riders with special needs reportedly experienced

strokes (PATH).

Music Therapy

Established in 1950, music therapy is a growing

service existing in multiple settings, including rehabilitation.

Taking treatment goals into consideration, a music

therapist helps to optimize the client’s health through

“various facets of music experience and the relationships

formed through them” (Bruscia, 2014, Chapter 4). These

board-certified music therapists are held to standards of

the American Music Therapy Association. Section C, item

18 of the association’s Professional Competencies requires

that music therapists be skilled in “interprofessional collaboration”

(AMTA, 2018). This means effectively working

with outside discipline members to design and implement

co-treatment of a shared client. However, almost no literature

exists regarding interprofessional collaboration between

music therapists and therapeutic riding instructors.

Related Literature

EAAT Effect on Persons with Stroke

Most literature regarding EAAT involves children

or adolescents – a lack of research exists on EAAT with

adults. A pilot study involving riders with chronic brain

disorders determined, based on an 8-week period, that

hippotherapy had the potential to improve gait and balance

training as a complementary treatment (Sunwoo,

Chang, Kwon, Kim, Lee, and Kim, 2012). Sunwoo et al.

69

concluded that these improvements were maintained 2

months after treatment (2012). Improvements in gait and

balance were also found in mechanical horseback riding

for stroke patients (Han et al., 2012). Pelvic stimulation

is provided by the natural movement of the horse. This

stimulation gives riders a rhythmic and regulated sense

of walking. Core-controlling muscles work to adapt to the

horse’s speed and rhythm. Challenging these muscles can

result in strengthened balance for riders.

A 12-week qualitative study investigated the effect

of multimodal therapeutic techniques on post-stroke participants

(Pohl, Carlsson, Kӓll, Nilsson, and Blomstrand,

2018). When studying horseback riding, they found that

the close physical contact with horses helped establish

an emotional connection between horse and rider. The

learning aspect of riding a horse acted as a positive reinforcement

for self-pride, courage, and self-efficacy. Broad

themes emerged such as transformative experience, human–horse

interaction, and togetherness and belonging

(Pohl et al., 2018). These psychological, social, and emotional

benefits likely increased the participants’ quality

of life. This may enhance the daily living experiences for

post-stroke patients.

Music Therapy Effect on Persons with Stroke

In Guidelines for Music Therapy Practice in Adult Medical

Care, Gilbertson gives an overview of the four methods

of music therapy that may be implemented with adults

with stroke (2013). These guidelines are in no way restrictive;

other interventions may be beneficial for persons

with stroke. Assessment of the client’s current skill levels

and needs will determine what interventions to practice.

Overview highlights as follows:

Receptive methods include music listening of client-selected

music to improve motivation and relaxation.

Improvisational methods include vocal improvisation in

which the therapist matches breathing, timbre, and rhythm

of the client. Re-creative methods include singing familiar

songs and encouraging the client to participate in singing,

70

and rhythmic speech cuing using a drum to mimic natural

rhythm in conversational speech. (Gilbertson, 2013).

A meta-analysis was conducted in 1996 to determine

music’s effect as a reinforcer in educational and therapy

settings (Standley). Contingent music was found to be

more effective than other contingent stimuli, and music

was highly effective in increasing desirable behaviors in

participants. Physical rehabilitation and developmental

behaviors were highly influenced by music contingencies.

The studies addressed attention and interactions such eye

contact, sitting posture, following directions, and imitating

a behavior. Education settings used contingent most frequently.

Individuals with complications resulting from a

stroke may benefit from the use of music as a reinforcer to

improve their cognition as determined by this meta-analysis

by Standley (1996). Examples of music reinforcement in

music therapy practice: instrument playing, singing preferred

songs, or playing a musical game.

A research study conducted in 2000 investigated

the impact of group music therapy on social interaction

and mood of rehabilitation residents who have had traumatic

brain injuries or strokes. The music therapy group

session structure began with an opening activity such

as instrumental improvisation with percussion/melodic

instruments. The bulk of the session included one to

two interventions involving singing, composing, playing

instruments, improvising, or listening. At the end of each

session, participants engaged in verbal processing of their

mood and experience. The researchers found that group

music therapy sessions increased social engagement and

improved mood of the participants when compared to a

control group who only received standard rehabilitation

(Nayak, Wheeler, Shiflett, and Agostinelli, 2000). Similarly,

Kim et al. concluded that music therapy led to improved

mood and lowered depression scores of post-stroke patients

(2011). Music therapy has been shown to increase

stroke patient motivation to participate in rehabilitation

and improve aspects of quality of life such as mood.

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Relational active music therapy (RAMT) sessions

were found to not only increase emotional communication

but also to significantly improve hand motility in stroke

patients (Raglio et al., 2017). RAMT sessions were based

on free conversation-like interactions between the client

and music therapist using rhythmic-melodic instruments

in a non-verbal setting. Emotions were expressed musically

and shared in an empathetic manner. Emotional communication

was likely reinforced by the validating nature

of empathy between the therapist and client. Motor functioning

of arms and hands were stimulated using musical

instruments. Motor functioning was likely encouraged by

the auditory feedback provided by the music created by

the participant.

Music Therapy in Collaboration with EAAT

Little to no literature exists regarding music therapy

in collaborative efforts with EAAT. Two professionals

are known to have integrated these treatments. Sr. Ann

Francis Thompson, a board-certified music therapist and

PATH certified riding instructor, has been practicing this

integration for almost a decade. Although music acts as a

distractive auditory stimulus, she found that music makes

riding exercises appear easier as well as provide a positive

distraction to redirect focus of the rider to the lesson

(Sr. A. F. Thompson, personal communication, September

24, 2018). She suggests taking tempo of songs into

consideration as the horse will entrain to given tempos

(Thompson, 2011). General categories listed on her center’s

website include: learning new riding skills, remembering

correct posture, relaxing a tense rider or horse, or creating

an enjoyable environment (Thompson, 2013).

Former intern of Sr. Thompson, Sarah Lynn Rossi,

conducted a feasibility and design study to examine interdisciplinary

collaboration of music therapy and EAAT

(Rossi, 2018). Popular and useful interventions that were

discovered included: hello/goodbye songs, waiting songs

(mount/dismount), task analysis songs, and music &

movement (S. L. Rossi, personal communication, September

24, 2018). Upon comparing positive and negative as-

72

pects of this collaboration on her eight study participants,

Rossi claimed that improvement with the addition of music

outweighs any threats of distraction or safety (2018).

No further literature was uncovered regarding

music therapy combined with EAAT. Seeing as this field

lacks comprehensive literature, more studies are needed

to determine the outcomes of the collaborative treatment.

This case study explored the product of newly introduced

music therapy interventions at a therapeutic riding center.

Additionally, this study provided direct documentation

on the participant, something absent in Rossi’s study.

Research Purpose

The purpose of this study was to examine the effect

of music therapy in combination with therapeutic riding

upon the motor skills and expressive communication of a

rider with quadriplegia resulting from a cerebral hemorrhage.

Research Questions

1. Can “music and movement” improve body awareness/

control for the subject?

2. Can musical cues and singing songs assist in expressive

communication skills for the subject?

3. Will “musical games” aid in decision-making and processing

skills of the subject?

4. Will music therapy aid in redirection and increase motivation

for the subject?

5. Is this interdisciplinary collaboration effective?

Participant

Background Information

The subject for this study was a 42-year-old, Caucasian

woman who experienced a cerebral hemorrhage at

the age of 16. This hemorrhagic stroke originated in the

left hemisphere and resulted in quadriplegia. She lives at

home with her single mother and receives multiple forms

of therapy including but not limited to speech and physical

therapy. The client has been riding at Born 2 Be Therapeutic

Equestrian Center for 4 years.

73

Medical Limitations

She has a spinal pump which provides a medication

drip for aiding in muscle control and managing muscle

spasms. The client uses a wheelchair for mobility and

wears molded heel braces for her ankle-foot orthosis. The

client has no function in her right arm – which is protected

in a sling – but has some functioning in her left arm. She

often experiences muscle pains in her legs and left arm

while riding. The stroke also severely affected her verbal

communication skills; respiration, phonation, and articulation

are hindered areas of her speech process. Due to her

medical condition she is prone to fatigue and therefore,

loss of motivation in activities.

Adaptive Behaviors

The client is often asked yes/no questions and has

adapted rapid eye-blinking to communicate “yes”. She

gives a thumbs-up to express comprehension and blows

kisses to express gratitude. Most of her adaptive behaviors

are to compensate for loss or difficulty in communication.

Other adaptive behaviors were not observed during the

study. The client did not present any self-abusive, aggressive,

or inappropriate behaviors.

Music Therapy Assessment

The researcher previously observed the client in

therapeutic riding lessons for at least 1 year. Music had

not been a resource in the lesson prior to the study. The researcher

considered this client for the collaborative study

due to her responding positively when the riding instructor

sang posture reminders such as “tall and beautiful”.

No formal or written music therapy assessment procedure

was utilized. Therapeutic goals were to increase motor

control and motoric skills and improve verbal communication

skills. Information regarding the client’s musical

preference was gathered from the rider’s parent; the client

preferred worship or country music. She was able to

follow musical prompts for some physical movements and

verbal commands to the horse. Although she could not

sing full phrases, she eventually sang a few words at the

ends of phrases.

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Research Methodology

Theoretical Orientation

The theoretical orientation of the researcher is

experiential-humanistic. The nature of this collaboration

was to provide a unique and enhanced experience for the

rider. Although improving the physical and verbal skills

was important to the researcher and riding instructor, the

emphasis was on the process rather than the outcome.

Additionally, the purpose of any pilot study is to gain

new knowledge, test the feasibility, and experience the

raw course of events. Therefore, this pilot collaboration

between music therapy interventions and equine-assisted

activities was best approached with an experiential-humanistic

theoretical orientation.

Setting

This study was held at Born 2 Be Therapeutic

Equestrian Center in Sanger, Texas, during the spring

of 2019. Founded in 2012, Born 2 Be is a PATH certified

therapeutic riding and driving center that serves people of

varying age and ability (Born 2 Be Therapeutic Equestrian

Center, n.d.). The center is a nonprofit organization that

relies on volunteers. This facility uses a covered arena, an

outside arena, and trail courses for riding. The center has

modified riding tack and mounting ramps for people who

need extra assistance while riding.

The researcher had been a volunteer at Born 2 Be

for 4 years prior to beginning this study. Having built

rapport with the volunteer coordinator and riding instructor,

the facility expressed interest and permission to proceed

with the collaborative case study. The center already

provided liability coverage for riders, volunteers, and staff

who participate in the therapeutic riding experience as

stated in their agreement policy; therefore, informal verbal

permission was granted by the subject’s parent for this collaborative

work.

Session Description

Intentions were to meet during the rider’s weekly

lessons for 8 weeks. However, due to the rider’s health

75

and scheduling conflicts only 6 sessions were attended

over a 3-month period. The last 4 sessions occurred consecutively.

Sessions typically lasted 35 minutes and directly

involved the rider, riding instructor, researcher, horse,

horse handler, and two side-walkers. The horse handler

manages the horse according to the rider’s independence

and the side-walkers assist the rider with balance and

steering. The volunteer coordinator and rider’s caretaker

observed each session. The rider’s health and weather

influenced the session environment. The researcher and

riding instructor achieved collaboration by leading every

other activity during the lesson and discussing strengths

and weaknesses afterwards.

Music Therapy Methods and Techniques

The four main methods of music therapy include:

receptive, re-creative, compositional, and improvisational.

For the purpose of this study receptive, re-creative, and

compositional methods were implemented.

The structure of every session started with a “Hello

Song” and ended with a “Goodbye Song”. These receptive

interventions did not require active participation

from the rider but prepared her for transitioning into or

out of the riding lesson. Most of every session consisted

of re-creative music therapy methods. The re-creative

songs prompted verbal or physical movement of the rider.

To bring finality to the study, the researcher composed

a unique song describing the rider and her capabilities

throughout the study.

Musical games. Song games were used to prompt

verbal commands and rein usage for basic riding skills

such as walking and stopping. When the music began, the

rider was to say, “walk on”, and hold her reins for control.

When the music stopped, she was to say, “whoa”, and

pull back on her reins to halt. Songs selected belonged

to the worship or country genre, as they were preferred

by the rider. Examples include: “You Are My Sunshine”,

“This Little Light of Mine”, and “Take Me Home Country

Roads”. This song game was performed at the beginning

of every lesson as a warm-up activity.

76

Music and movement. This activity recreated the

classic, “If You’re Happy and You Know It” song and set

movement and speech to music. The rider was prompted

to complete three actions of saluting, petting the horse,

and shouting “yeehaw” while riding around the arena and

reversing direction. Saluting stimulated use of her only

functioning arm. Petting the horse required the rider to increase

her abdominal support in order to lean forward and

pet her horse on the neck. Shouting “yeehaw” required the

rider to increase and strengthen her breath support and

provided a silly way for her to be as loud as she wanted –

as she mostly spoke quietly.

Social involvement. Opportunities for social interaction

may be stunted in the rider’s daily life due to her

health condition or her difficulty in speaking. The transition

songs and the music and movement activity in the

sessions provided the rider a chance for social engagement

with the volunteers, the horse, the riding instructor, and

the researcher. For example, the “Hello Song” involved

singing hello to everyone – including the horse. During

the lesson the volunteers, riding instructor, and researcher

often gave praise for successful motor control or loud and

clear speech; the rider returned the gratitude with blowing

kisses.

Treatment Process

Phase One

This phase consisted of the initial introduction

of music to the client’s riding lesson. “Hello Song”, the

musical games, and the music and movement activity

were all introduced. The rider seemed interested in the

interventions as she visually tracked the researcher when

there was singing and guitar playing. The rider appeared

to have difficulty remembering the order of the movement

activity and needed extra processing time. There were

stagnate moments during collaboration where neither

the researcher nor the riding instructor understood who

was leading next. The researcher found it difficult to walk

backwards in a riding arena while singing and playing the

77

guitar.

Phase Two

The middle phase comprised gaining familiarity of

the interventions for the rider, researcher, and riding instructor.

The rider had declined in health and experienced

chest congestion and muscle cramps in her legs. Despite

poor health, it was at this point of the study that the rider

began singing a few words with the researcher. The rider

was also unexpectedly expressive when she learned it

was “Volunteer Appreciation Week”, by saying “thank

you”. At the end of this phase, the rider required less time

to process information and was anticipating upcoming

actions during the movement activity. The collaboration

between the researcher and riding instructor became

smoother and more predictable.

Phase Three

The final phase of this case study began with significant

setbacks due to the rider’s spinal pump not administering

enough medication. After receiving medical help

from a physician, the rider had better muscular control

and less spasmic motions in her legs. The rider verbalized

for most of the musical game trials. During the movement

activity, she demonstrated much improved body control

and seemed to have fun doing all three actions, as evidenced

by smiles and laughing.

To bring a sense of closure, the researcher prepared a special

goodbye song using the melody of “Deep in the Heart

of Texas” – utilizing descriptions of the rider’s physical

and original characteristics noticeable in the lessons. The

rider sang her name in the tag of every verse and laughed

at the humor in the song. Feedback surveys were collected

at the last session and closing remarks were shared.

Evaluation

Fieldnotes

Fieldnotes consisting of objective and subjective

information were documented after each session. These

notes described those present at the lesson, the lesson plan

78

– which was designed by the riding instructor – a description

of the interventions used and how the rider responded,

quotes from those present, and a personal reflection.

(See “Fieldnotes”)

Feedback Surveys

Feedback surveys were collected from the rider’s

parent, riding instructor, volunteer coordinator, and a volunteer

at the end of the study. The survey included yes/no

questions, Likert rating scales, and open-ended questions.

The survey measured awareness of music therapy, opinions

regarding the influence of music on the rider, and

collected commentary about the overall study. (See “Appendix”)

Discussion

Strengths

The researcher had a previous background in

working with Born 2 Be as a horse leader and side-walker,

which enhanced the understanding between the riding-related

goals and music therapy goals; this history also gave

the researcher insight into creating a safe environment

with musical stimuli and the horse. The facility and their

volunteers seemed eager to participate in the collaboration;

music therapy advocacy and awareness was achieved

as 75% of the survey responders did not know of music

therapy prior to the study. This was a ground-breaking

case study for music therapy combined with equine activities

and gave specific insight into working with a woman

who has stroke-induced quadriplegia in this situation.

Through observations by the researcher and the riding

instructor, the treatment combination had a positive effect

on the rider’s motivation which directly impacted her

willingness to participate verbally and physically in her

lessons. Commentary in the feedback surveys included

acknowledgment of the increase in the rider’s participation

and attention, and the creation of a relaxed and encouraging

environment for everyone involved. The riding

instructor wrote, “amazed at how quickly the student

responded to the music therapy and the difference it made

79

in her communication in such a short time,” (T. McCarty,

personal communication, April 26, 2019). The repetition of

familiar material decreased the rider’s processing period

to make decisions regarding motoric and verbal responses.

Music therapy was found to be a beneficial addition to the

riding lesson and aided the rider in reaching motor and

communicative goals.

Limitations

The inherent qualities of a pilot study lack a history

of supporting evidence and literature. Future research is

needed in the collaboration between music therapy and

equine-assisted activities. The limited number of sessions

does not provide information on long-term effects that

this treatment combination may have on the physical and

communicative skills of the rider. Also, the inconsistency

of the frequency of the sessions may not have produced

optimal results.

More detailed lesson planning between the riding

instructor and researcher may have led to more effective

collaboration and more detailed objectives. This change

might have utilized all music therapy methods in the

lessons and provided experimentation opportunities with

other music experiences such as improvisation and relaxation.

The study did not give the rider a chance to participate

nonverbally in the music via drums or other instruments.

Additionally, the researcher’s previously established

relationship with the facility and those who work

there may have skewed the results from the feedback surveys.

They may have given biased responses in the survey

to please the researcher.

Implications

The experiential-humanistic theoretical approach

by the researcher allowed for emphasis on the overall

experience; this was found to be a creative and fun environment,

a unique treatment pairing opportunity, and

an increased social connection for all who participated.

The resulting effects on the rider’s motivation, cognitive

processing, body control, and expressive communication

80

imply that this collaborative experiment was successful.

This pilot case study demands further research with clients

of varying age and ability, group vs individual riding

lessons, and other therapeutic riding facilities. Other research

opportunities include the logistics of a professional

partnership between a therapeutic riding instructor and a

music therapist.

References

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musictherapy.org/about/competencies/

Born 2 Be Therapeutic Equestrian Center. (n.d.). Retrieved

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Han, J. Y., Kim, J. M., Kim, S. K., Chung, J. S., Lee, H-C.,

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Kim, D. S., Park, Y. G., Choi, J. H., Im, S-H., Jung, K. J.,

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Raglio, A., Zaliani, A., Baiardi, P., Bossi, D., Sguazzin, C.,

Capodaglio, E., … Imbriani, M. (2017). Active music therapy

approach for stroke patients in the post-acute rehabilitation.

Neurological Sciences, 38(5), 893-897. doi: 10.1007/

s10072-017-2827-7

Rossi, S. L. (2018). Interdisciplinary collaboration between

music therapy and therapeutic riding: Feasibility and

design (Master’s thesis). Retrieved from ProQuest Dissertations

and Theses database. (Order No. 10983987).

Standley, J. M. (1996). A meta-analysis on the effects of

music as reinforcement for education/therapy objectives.

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Journal of Research in Music Education, 44(2), 105-133.

doi: 10.2307/3345665

Sunwoo, H., Chang, W. H., Kwon, J-Y., Kim, T-W., Lee,

J-Y., Kim, Y-H. (2012). Hippotherapy in adult patients

with chronic brain disorders: A pilot study. Annals of

Rehabilitation Medicine, 36(6), 756-761. doi: 10.5535/

arm.2012.36.6.756

Thompson, Sr. A. F. (2011, November). Using music to

enhance therapeutic riding. Professional Association of

Therapeutic Horsemanship International Conference.

Symposium conduced at the meeting of PATH Intl. Lexington,

KY.

Thompson, Sr. A. F. (2013). Music therapy on horseback.

Retrieved from http://equestcenter.org/music-therapy-on-horseback/

83

Treatments and Causes of Idiopathic Hypersomnia

Yurimar Santiago-Torres

What are Sleep Disorders?

As a primary need for humans, sleep takes a major

part in our brain function, emotional well-being, physical

health, daytime performance, and safety. The Sleep in

America® poll, a random national sample conducted by

the National Sleep Foundation in 2018, shows that only

10% of participants consider sleep as their major priority

compared to fitness/nutrition (35%), work (27%), hobbies/

interests (17%), and social life (9%) (National Sleep Foundation,

2018). This year, the NSF conducted another poll

showing that having a healthy sleep is strongly related to

maintaining a schedule. The results were that only 30%

of the participants maintain a consistent sleep schedule

in weekdays, and only 38% in weekends (National Sleep

Foundation, 2019).

Sleep disorders are defined as the changes in the

quality and amount of sleep, leading to lack of productivity

and causing tiredness and distress during daytime

activities. When having a poor sleep health (maintaining

irregular sleep schedules) there’s a tendency to encounter

symptoms of fatigue, increased somnolence, irritation,

decreased energy, and problems with focus and decision-making

(Boucetta et al., 2017). The inconsistency with

the maintenance of our biological sleep needs has turned

into a major concern in the 21st century. Despite having

the capability of adjusting our sleep routines to decrease

professional help, it has been continuously seen as a secondary

priority by affected individuals.

Central Disorders of Hypersomnolence

Distinctions between sleep deprivation and hypersomnolence

disorders are: having a sleep schedule

of –at least- seven hours while still experiencing excessive

daytime sleepiness (EDS or hypersomnolence); an

uncontrollable need to sleep even during daytime. This

84

response remains for at least three months with or without

prolonged nighttime sleep (Barateau, Dauvilliers, Lopez,

& Franchi, 2017). An individual with EDS may sleep 9+

hours, have additional sleep periods during the day, and

it will still be unrefreshing. Among the central disorders of

hypersomnolence that share commonalities are Narcolepsy

Type 1 (NT1), Narcolepsy Type 2 (NT2), and Idiopathic

Hypersomnia (IH).

Narcolepsy Type 1 & Narcolepsy Type 2

Narcolepsy is a central disorder of hypersomnolence

and a chronic and neurological disorder. The

symptoms can include excessive daytime sleepiness, sleep

drunkenness, cognitive dysfunction, disrupted nocturnal

sleep (mostly on NT1), and abnormal sleep patterns

(Bollu, Manjamalai, Thakkar, & Sahota, 2018). This refers

to non-REM (rapid eye movement) and REM sleep. In a

normal sleep pattern, before the REM stage the body goes

through three non-REM sleep stages. The first stages start

with a reduced consciousness, the beginning of a light

sleep, heart rate starts to slow down, body temperature is

regulated, and muscles relax. The third stage of non-REM

sleep is known as the restorative stage of sleep or slowwave

sleep, in which the body increases blood supply to

the muscles and bodily awareness is lost. Usually, each

stage lasts from 5-15 minutes. Lastly the REM stage is

reached, and rapid movement of the eyes occur, the body

temperature changes, brain activity increases (similar to

the brain activity when awake) and as a result, dreams

take place (Bollu et al., 2018).

Contrasting with narcolepsy patients, REM sleep

happens within 15 minutes of falling asleep. Because

of the rapid blend of stages, additional symptoms may

include hypnogogic hallucinations and sleep paralysis. Patients

with NT1 present an additional symptom called cataplexy,

which is experiencing a sudden muscle weakness

triggered by strong emotions of anger, sadness, surprise,

or laughter (Bollu et al., 2017). The weakness lasts no more

than two minutes and it can involve numbness in face,

head, and body collapse. The exact cause of NT1 and NT2

85

remains unknown.

What is Idiopathic Hypersomnia?

As NT1 and NT2, idiopathic hypersomnia is a

chronic neurological disorder and a central disorder of hypersomnolence.

Shared symptoms include excessive daytime

sleepiness (more than 9 hours), sleep drunkenness,

and cognitive dysfunction. Compared to NT1 there’s no

presence of cataplexy. Additional symptoms include unrefreshing

daytime naps (usually more than 1 hour), motor

hyperactivity serving as a “boost” to stay awake, headaches,

problems with balance, automatic behaviors, and a

fluctuating severity (Hypersomnia Foundation, 2019). Additional

criteria for IH includes having the presence of an

average sleep latency of <8 on the Multiple Sleep Latency

Test (MSLT), having none or no more than two sleep onset

REM periods (SOREMPs) which refers to having REM

sleep periods within 15 minutes of falling asleep, and that

the excessive daytime sleepiness is not being caused by a

coexisting condition, medication, or substance abuse.

History Overview of IH

The term ‘hypersomnia’ originated with the physician

Bedrich Roth from Czechoslovakia in the late 1950s

(Billiard & Dauvilliers, 2001). He initially names it ‘sleep

drunkenness’ and ‘hypersomnia with sleep drunkenness’.

In one of his first studies, Roth collected data from 642

observed cases over a period of thirty years. A total of 167

of the patients suffered from IH. He found there was a

family history of EDS in a third of patients and symptoms

were reported as continuous (Anderson et al., 2007). Roth

described many differences between narcolepsy without

cataplexy (NT2) and IH. From this point on, even though

there are not many case series, studies have been made to

understand IH from other EDS disorders. A study of 77

cases of patients with sleep disorders conducted in 2007

showed that compared with narcolepsy, IH patients were

more likely to have sleep drunkenness, to have a nighttime

sleep of more than nine hours, naptime durations of

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more than an hour, and a night sleep efficiency of more

than 90% (Anderson et al., 2007). However, with a small

number of case series and an unknown pathophysiology,

variations in response to treatment and a relatively small

population with IH, it is difficult to determine the efficacy

of the diagnosis.

Pathophysiology of IH

As mentioned, the cause of idiopathic hypersomnia

remains unknown and debatable. The state of alertness

and sleep is controlled by different neuronal systems in

the brain. The circadian rhythm and homeostatic process

use alertness and sleep promoting neurotransmitters to

take effect on the sleep-wake cycle rhythms of the brain

(Bollu et al., 2018) through many neurochemicals. A proposed

theory by David Rye, PhD, of Emory University,

suggests the role of GABA in IH by promoting sleep

through inhibition of wake promoting brain regions. This

is the main inhibitory neurotransmitter in the central

nervous system that promotes sleep. In their research it

was identified an endogenous molecule referring to it as

a somnogen (sleep-promoting agent) in the cerebrospinal

fluids of IH patients. This unknown molecule increases the

activity of GABA receptors, suggesting that problems with

wakefulness are not related to a defect in wake-promoting

transmitters but due to immoderate activity of GABA (Rye

et al., 2012).

In 2015, research conducted on genetically altered

mice in the Centre of Neurotechnology, Imperial College

London, demonstrated the complex interactions of

GABA and Histamine controlling wakefulness and somnolence.

Histamine acts as an excitatory neurotransmitter

responsible for keeping us awake. It is also responsible

for alertness, motivation, and perception. This substance

is produced by a neuron that also contains GABA, called

tuberomammillary nucleus (TMN). In the study, scientists

manipulated a gene in mice called vgat (in humans

SLC32A1), which codes to build a protein named vGAT.

This protein is present in GABAergic neurons and is nec-

87

essary for GABA to be transported into synaptic vesicles

and be released from nerve endings. In the experimental

group of mice, the vgat gene was inactivated in the TMN.

After putting each mouse in cages and measuring their

activity scientists found that the experimental mice were

hyperactive during the tests and sleepless when limiting

the amount of sleep, showing significantly less non-REM

sleep. The results suggest that Histamine and GABA released

from histaminergic neurons regulate the quality of

sleep and wakefulness. The results found in both studies

recognize the possible roles of GABA with brain systems

necessary for sustaining wakefulness. Suggestions for new

treatment options for patients with IH is still limited.

Pharmacological Treatments for IH

Treatment for hypersomnia, to be effective, should

be directed to its cause with a balanced medication and

sleep schedule (Bollu et al., 2018). As explained through

the last section, the small number of available IH researches

and case series continue to postpone the finding of an

effective medication. Currently, the United States Federal

Drug Administration (FDA) has no approved medications

for the treatment of IH. The offered treatment for IH

patients is FDA approved only for NT1 & NT2, excluding

the medications for cataplexy in NT1. The traditional

medications for IH treatment are: Modafinil, Armodafinil,

Methylphenidate, Amphetamine-dextroamphetamine, and

dextroamphetamine.

Modafinil tends to be the first pharmaceutical option

when beginning treatment (Trotti, 2017). It was first

made and used in France for the treatment of narcolepsy

during the 1980s. It is considered to be developed from an

active metabolite of adrafinil used as an off-label cognitive

enhancer for the elderly (Mignot, 2012). Currently, it is catalogued

as a Schedule IV controlled substance primarily

used for narcoleptics and related EDS disorders as hypersomnia.

IH Patients Response to Modafinil Treatment

The abuse and dependence potential of modafinil

88

remains rare. Minor side effects such as headache, nausea,

dizziness, insomnia and anxiety may occur, with the most

common being headache and nausea (Bollu et al., 2018).

The mechanisms of modafinil are still debatable. However,

it is thought to involve a relatively selective dopamine

reuptake inhibition (Mignot, 2012). This means that

modafinil blocks the reuptake of dopamine in pre-synaptic

neurons increasing the levels of dopamine in the synapse.

High concentrations of dopamine remain available, eventually

binding to post-synaptic receptor sites and influencing

on the sleep-wake rhythm of the brain. Clinical

series of IH patients treated with Modafinil demonstrate

a total sample size of 226 patients being prescribed with

modafinil, and 197 continuing treatment. 63% of patients

(124/197) remained on modafinil with good response

(Trotti, 2017). These experiences suggest that modafinil

usage from 100mg to approximately 200mg twice a day,

is effective in at least half of the patients or too weak for

a stimulant. Suggestions to add a dose of a short-acting

stimulant (such as methylphenidate) at times when

alertness is challenging to keep, remains encouraged by

many researchers (Mignot, 2012). A greater representation

of modafinil versus methylphenidate is seen in a retrospective

review of 997 patients with IH seen at the Mayo

Center for Sleep Medicine from 1996-2007 (Ali, Auger, Slocumb,

& Morgenthaler, 2009). Methylphenidate was most

commonly used until Modafinil became the most common

drug in late 1990s. In the last recorded visit of 85 patients,

methylphenidate had a higher percentage of effectiveness

or partial effectiveness (51% vs. 32%) compared to modafinil

(Ali et al., 2009). It was also found as a recurring complaint

the high cost of modafinil compared to the low cost

of methylphenidate in almost 80% of the patients (Ali et

al., 2009). Economic factors can be considered as a reason

to stop treatments for idiopathic hypersomnia. Continuing

research is important to guarantee pharmaceutical treatments

that are fully effective in a considerable number

of patients, safe, affordable, and approved for idiopathic

hypersomnia treatment by the FDA.

89

References

Ali, M., Auger, R. R., Slocumb, N. L., Morgenthaler, T. I.

(2009). Idiopathic hypersomnia: clinical features and response

to treatment. Journal of Clinical Sleep Medicine, 5(6),

562-567.

Anderson, K. N., Pilsworth, S., Sharples, L. D., Smith, I. E.,

Shneerson, J. M. (2007). Idiopathic hypersomnia: A study

of 77 cases. SLEEP, 30(10), 1274-1281.

Barateau, L., Lopez, R., Franchi, J.A. M., Dauvilliers, Y.

(2017). Hypersomnolence, hypersomnia, and mood disorders.

Sleep disorders, 19(13), 1-11.

Billiard, M., Dauvilliers, Y. (2001). Idiopathic hypersomnia.

Sleep Medicine Reviews, 5(5), 351-360.

Bollu, P. C., Manjamalai, S., Thakkar, M., Sahota, P. (2018).

Hypersomnia. Science of Medicine, Sleep Medicine Series,

115(1), 85-91.

Boucetta, S., Montplaisir, J., Zadra, A., Lachapelle, F.,

Soucy, J. P. (2017). Altered regional cerebral blood flow in

idiopathic hypersomnia. SLEEP, 40(10), 9-10.

Langer Research Associates of New York, National Sleep

Foundation. (2018). Sleep & effectiveness is linked, but few

plan their sleep. Sleep in America Poll, 1-5.

Langer Research Associates of New York, National Sleep

Foundation. (2019). Sleep health & scheduling. Sleep in

America Poll, 1-10.

Mignot, E. (2012). A practical guide to the therapy of narcolepsy

and hypersomnia syndromes. Neurotherapeutics, 9,

739-752.

Trotti, L. M. (2017). Idiopathic hypersomnia. Sleep Med

90

Clin, 12(3), 331-344.

91

Obesity: Genetics or Epigenetics?

Lily Sebastian

Obesity is one of the most prevalent conditions affecting

today’s society. Characterized by a BMI of at least

30 kg/m2, this condition tends to affect more females than

males and can be seen in people all over the world (1). It

is known that the method by which the body stores fat is

at play in the development and progression of obesity (2).

Additionally, there has been increased research done to

show that the gut microbiota has a significant effect on the

mechanism by which the body stores and burns fat, which

affects overall body weight (2). Due to the predominance

of this condition today, there has been a strong focus on

finding the most effective treatments for obesity. The most

commonly suggested treatment by healthcare professionals

continues to be to diet and exercise, which usually falls

into a simple balance of calorie expenditure exceeding

calorie intake (2). Additionally, obesity can be controlled

using pharmaceutical methods.

However, overall, it seems that these methods have

not proven to be very effective in the treatment of this

condition, as obesity is still a major concern today (2). As a

result, there has been increased research into other potential

factors at play in the development of this condition,

such as genetics and epigenetics (2). Genetics is defined as

the heritable traits that one inherits from his or her parents,

while epigenetics refers to how one’s environment

affects the expression of one’s genes. This paper explores

how obesity is affected by the interplay of genetics and

epigenetics and which one causes the greater effect on the

development of obesity.

Moreover, in the United States, the prevalence of

obesity has risen considerably over the past thirty years,

as about 35% of American adults today are obese, and

that number is only expected to increase in the near future

(3). It is important to understand the implications of how

genetics and epigenetics are involved in obesity, as it can

potentially be used to decrease these prevalence rates in

92

the future. To elaborate on this point, there are various

genetic factors that have been identified to impact whether

someone is more or less likely to become obese, such

as multiple single nucleotide polymorphisms (SNPs) and

genetic variants (3).

Concerning the genetic factors at play in the development

and progression of obesity, there have been about

180 SNPs as well as about 32 genetic variants identified

to be involved (3). One very impactful study showing the

predominance of genetics involved in weight gain was

performed by Bouchard et al. in 1990 (1). Dr. Bouchard

and his team had recruited twelve pairs of identical twins;

by doing this, he created an environment that controlled

for the similarity in genes between the two people in each

pair (1). Over the course of about 3 months, the participants

were fed an extra 1,000 Calories per day, and as

a result, there was an increase in body weight observed

amongst all of the participants (1). The most noteworthy

finding was that within each pair, there was a very small

change in weight gained; however, among the different

pairs, there was up to a 10-kilogram weight gain difference

(1). Based on this data, it was observed that there was

a strong genetic predisposition to weight gain. Furthermore,

another study, which was done by Stunkard et al.,

also examined whether genetics was a significant factor

in whether someone gained weight or not (1). Their findings

showed that more 50% of the difference in BMI was

attributable to one’s genes – the remaining change in BMI

was implied to by caused by the environment in which

one grew up (1). The Stunkard study, which focused on

the BMI variance among twins, both monozygotic and

dizygotic, raised together versus apart was instrumental in

bringing more awareness to the potential effects of one’s

environment, or epigenetics, on the expression of certain

genetic factors on weight gain (1).

Furthermore, to what extent does epigenetics affect

whether or not someone will become obese? In 2007, there

was a study that showed that increased physical activity

decreased obesity risk in a certain allele by about 10% as

93

compared to those who exercised less (3). This study was

confirmed in multiple populations, showing potential implications

of the large role of physical activity in decreased

obesity risk, beyond simply increased calorie expenditure

(3). The particular genetic variant whose expression was

impacted by the amount of physical activity was FTO,

and this gene is responsible for modulating how many

calories one’s body burns as well as appetite control (3).

There were particular SNPs located in close proximity to

the FTO gene which have been correlated to weight gain

or loss and affects the expression of FTO (3). This study

was performed on Caucasian male and female adults, but

no significant results in gene expression associated with

exercise was noted among the females (3).

Moreover, the above study was extended to include

both men and women of African American heritage, and

it was found that increased physical activity impacted the

communication between the BMI-related SNPs and the

FTO gene for the men, not the women (3). It was noted

that there was a much greater interaction between FTO

and the SNPs to promote weight gain in those with very

low levels of physical activity versus the positive effect of

weight loss on those with high levels of physical activity

(3).

Additionally, in 2000, Ravussin & Bouchard published

a model that examined how “restrictive” and “obesogenic”

environments affected individuals who were

“obesity-resistant (OR)” or “obesity-prone (OP)” (3). The

model they developed was instrumental in tying together

the effects of genetics and epigenetics on obesity in a way

that had not been seen before. As illustrated by Figure 1,

it was depicted that under a restrictive environment, both

the obesity-resistant and the obesity-prone individuals

would see no significant increase in their BMI (3). On the

other hand, under an obesogenic environment, both the

obesity-resistant and obesity-prone individuals would see

an increase in their BMI, albeit the obesity-prone individuals

would have a much larger increase in comparison

(3). As depicted in Figure 2, this can also be expressed in

94

terms of a bell curve; there tends to be greater increases in

BMI in individuals on either side of the bell curve (3). For

example, those with extremely high BMI’s initially will see

a much greater increase in their BMI when subjected to

an obesogenic environment in comparison to individuals

with an initially lower BMI (3). This pattern can be seen in

both children and adults alike, and it is a quite interesting

observation because it shows the effects of environment

on whether someone actually will become obese in their

lifetime. The classifications of OR and OP do indeed refer

to one’s genetic propensity of becoming obese, but the

environment to which one is exposed determines how and

if at all those genes are expressed.

Figure 1: BMI distributions in obesity-resistant versus obesity-prone

individuals under restrictive and obesogenic environments (3)

Figure 2: Changes in BMI in response to restrictive and obesogenic

environments in obesity-resistant versus obesity-prone individuals (3).

95

Moreover, it is important to mention that the main

ways epigenetics occurs includes DNA methylation,

histone modification, microRNA (miRNA) activity, and

more (4). These factors are significant because they alter

the expression of certain genes, which has the power to

drastically change various elements of one’s life. As seen

in Figure 3, DNA methylation occurs in various life stages

and is impacted by a variety of factors, including alcohol,

toxins, inflammation, dietary components, and potentially

exercise (4). A pertinent example of DNA methylation in

response to environmental factors is the case of bisphenol

A (BPA). A potentially harmful compound that tends

to hypomethylate DNA, BPA is found in certain plastic

products, such as water bottles (4). It has been found that

if fetuses are exposed to BPA while in utero, their Agouti

gene, which is involved in weight gain and loss, gets

hypomethylated (4). And as a result, these fetuses have a

higher chance of becoming obese as they grow and mature

in life; however, it has been discovered that simultaneous

exposure to methyl donors counteract the hypomethylation

effects of BPA (4). Some methyl donors include

genistein and folic acid, which function to increase the

methylation of the Agouti gene, resulting in a lower likelihood

of the fetus becoming obese (4). Consumed via the

mother’s diet during pregnancy, these methyl donors provide

convincing evidence of the importance of nutrition in

disease prevention and progression (4).

96

Figure 3: Figure 3: Effects of environmental factors on DNA methylation

over the course of a lifetime (4).

Since obesity has been linked to increased risk factors

of developing lifestyle disorders such as type 2 diabetes

and cardiovascular disease, the more information that

it discovered about obesity can help improve the health

and quality of life of many people globally. Furthermore,

the continued research that is being done is essential to

understanding the effects of both genes and the environment

on the prevention, development, and progression

of obesity. Based on the observation of the BMI difference

in twins that were raised apart versus together and the

discovery of the interactions between the environment-induced

SNPs and the FTO gene, there is persuasive data

showing the potential effects of the environment on obesity.

Additionally, the obesity pattern model developed by

Ravussin and Bouchard further showed how that while

genes do determine the degree of expression of obesity-related

genes, it is the environment that initiates that expression,

if at all. Lastly the impact of BPA on the methylation

of the Agouti gene while in utero provides solid evidence

that there is indeed a strong connection between environmental

toxins and obesity. Overall, there is sufficient

evidence to infer that epigenetics may indeed impact the

progression of obesity more so than genetics.

Summary

While genetics and epigenetics are both at play in

the progression and development of obesity, there is sufficient,

convincing evidence showing the impactful nature

of epigenetics more-so on the condition. From BMI differences

in twins to certain SNPs to the effects of bisphenol

A (BPA) in utero, it can be seen that the environment, in

conjunction with one’s genetics, does play an important

role in obesity. Defined as the impact of environment on

the expression of one’s genes by means of various methods

such as DNA methylation, histone modification, chromosome

shape alteration, or even microRNA function,

97

epigenetics is integral in modulating the DNA to RNA to

protein process. Not confined to one period of time, epigenetics

is at play in utero, throughout adulthood, and

beyond. Obesity affects many people and is expected to

affect many, many more in the near future. Being obese

increases one’s chance of developing complicated lifestyle

disorders such as cardiovascular disease and type 2 diabetes.

The purpose of performing research that explores

the potential effects of epigenetics and genetics on obesity

is to find more promising treatment modalities, perhaps

concerning nutrition and exercise as well as pharmacological

methods, to curb the progression of obesity and other

related lifestyle conditions.

References

1. Ravussin, E., and Swinburn, B. A. (1992). Pathophysiology

of obesity. The Lancet 340(8816): 404-408. doi:http://

dx.doi.org.ezp.twu.edu/10.1016/0140-6736(92)91480-V

2. Scully, T. (2014). Obesity. Nature 508(7496 SI), S49. Retrieved

from https://link-gale-com.ezp.twu.edu/apps/

doc/A366729946/GPS?u=txshracd2583&sid=GPS&xid=7fd5501d

3. Demerath E. W. (2012). The genetics of obesity in transition.

Collegium antropologicum 36(4): 1161–1168.

4. Campión, J., Milagro, F. I. and Martínez, J. A. (2009).

Individuality and epigenetics in obesity. Obesity Reviews

10: 383-392. doi:10.1111/j.1467-789X.2009.00595.x

98

Stone, Steel, and the Art of Propaganda:

A Comparative Study of Augustus of Primaporta

and Soviet Worker and the Collective Farm

Woman.

Abby Weatherford

The relationship between art and propaganda is

often difficult to discern. Some might consider the two

items entirely separate classes of cultural dissemination,

while others see them as deeply intertwined. The latter

belief is perhaps more correct; Stern considers it “futile” to

argue that propaganda cannot employ art. 1 Indeed, propagating

a political message via art often proves successful.

Joseph Goebbels, Hitler’s minister of propaganda, noted

that the term “propaganda” frequently seems insidious to

the masses. 2 Consequently, masking propaganda with art,

particularly “great” art, more effectively transmits a political

message. Examples of this tactic exist across cultures.

Ancient Rome and the USSR serve as particularly useful

examples in the study of propaganda and art. Within these

cultures, Augustus of Primaporta and Soviet Worker and the

Collective Farm Woman serve as useful data points. Though

both statues emerged from similar historical contexts and

used similar techniques, Augustus of Primaporta exalts a

man and his society while Soviet Worker and the Farm Woman

exalts a society and its men.

Augustus of Primaporta, 3 carved in marble by an

unknown artist, dates from the first century CE, though

scholars believe it could be a marble copy of a bronze

1 Stern, Madeleine B. “Propaganda or Art?” The Sewanee

Review45, no. 4 (1937): 453. http://www.jstor.org.ezp.

twu.edu/stable/27535377.

2 Sooke, Alastair. “Can Propaganda Be Great Art?”

BBC, October 21, 2014. http://www.bbc.com/culture/story/20130703-can-propaganda-be-great-art.

3 Augustus of Primaporta, 1st century AD, marble,

6’8”, Musei Vaticani, Braccio Nuovo, Rome.

99

dated 20 BCE. 4 One of about 140 portraits of Augustus 5 ,

Augustus of Primaporta is larger than life. At nearly seven

feet tall, the statue implies massive strength in its subject,

shown in the prime of life. He stands in the pose of a

Roman orator, reaching out his hand in adlocutio, a gesture

of public address. 6 Cupid rides a dolphin near Augustus’s

right foot, referencing Augustus’ relation to the divine

Venus. 7 Though Augustus wears military garb, his feet

lack the boots of Roman soldiers. Thus, Augustus appears

more like an epic hero than a mortal soldier. 8 His breastplate

shows, in relief, Roman victory over the Parthians.

The Parthian king hands over his standard as the Roman

gods and a personification of the Pax Romana watch. These

elements, though nominally telling the story of Roman

victory, underscore Augustus’ greatness.

Soviet Worker and the Collective Farm Woman 9 is of

similarly grand proportions. Created for the 1937 World’s

Fair, it embodies a spirit of determination for Russia.

Twelve tons of steel reach twenty-four meters—approximately

eighty feet—into the sky. 10 A man and woman, of

4 Stokstad, Marilyn, Michael W. Cothren, and Michael

Cothren. Art History. 5th ed. Pearson, 2014, 134.

5 Becatti, Giovanni. The Art of Ancient Greece and

Rome: From the Rise of Greece to the Fall of Rome. Translated

by John Ross. New York: Harry N. Abrams, Inc., 1968, 313.

6 bid., 313.

7 Stokstad, Marilyn, et al. Art History. 5th ed. Pearson,

2014, 172.

8 Edmondson, Jonathan, and Associate Professor

Department of History Jonathan Edmondson. Augustus.

Edinburgh, United Kingdom: Edinburgh University Press,

2009, 303.

9 Vera Mukhina, Soviet Worker and the Collective Farm

Woman, 1937, stainless steel, Russian Exhibition Centre,

Moscow.

10 Kojoyan, Levon “Worker and Kolkhoz Woman:

from Propaganda to Nostalgia” (paper presented at the

Undergraduate Symposium in the History of Art, University

of Maryland, April 29, 2011), 11, http://drum.lib.umd.

100

equal size, reach into the air as they stride forward. The

woman holds a sickle, a traditional class marker for peasant

women. 11 The man, wearing a blacksmith’s apron,

holds a hammer, a class marker for peasant men. Together,

the hammer and sickle form a coat of arms for the Soviet

proletariat. 12 These two figures, then, embody the working

class of the USSR. They have united and consequently

lost their chains. 13 The sense of motion seen in these two

figures is deliberate: they are symbolically striding into the

future.

As with most political art, Augustus of Primaporta

was created within a distinct historical context. Augustus,

originally named Octavian, was born in 63 BCE 14 to a politically

prominent family. 15 After Julius Caesar’s assassination

in 44 BCE, his will named his great-nephew Octavian

his heir. 16 This proved pivotal in the career of Octavian,

now called Octavius. Though only eighteen or nineteen

years old, he found himself entangled in political rivalry

and turmoil. 17 He allied with Mark Anthony and Lepidus,

forming the second triumvirate in 43 BCE. 18

A man of considerable political savvy, Octaviedu/handle/1903/11372

(accessed December 30, 2016).

11 Victoria Bonnell, “The Peasant Woman in Stalinist

Political Art of the 1930s,” American Historical Review, vol.

98, no. 1 (February 1993): 63.

12 Ibid., 79.

13 “Workers of the World, Unite.” Oxford Reference.

Accessed July 8, 2019. https://doi.org/10.1093/oi/authority.20110803124745553.

14 Mark, Joshua J. “Augustus.” Ancient History Encyclopedia,

May 4, 2018. https://www.ancient.eu/augustus/.

15 Edmondson, Jonathan, Augustus, 1.

16 Mark, Joshua J. “Augustus.” Ancient History Encyclopedia.


18 Nguyen, Minh-ah. “Augustus and His Agenda.”

University of Washington, September 18, 2005. https://

depts.washington.edu/hrome/Authors/minhan/Augustusandhisagenda/pub_zbarticle_view_printable.html.

101

us spent years polishing his public image. For example,

Octavius ordered statues detailing his successes, tacitly

downplaying the efforts of Mark Anthony and Lepidus.

Furthermore, he requested the deification of Julius Caesar.

Octavius emphasized this deification not out of reverence

for his adopted father, but purely for political advantage. 19

Because Julius Caesar was now a god, his adopted son—

Octavius—was also divine. Ovid wrote, “Julius Caesar

had to be made a god that Augustus might not be sprung

by mortal blood” 20 . This divine status could compete with

the military successes of Mark Anthony and Lepidus. 21

Indeed, Augustus of Primaporta will reveal an emphasis on

divine endorsement.

Military conflicts combined with Octavius’

long-running program of undermining Mark Anthony

and Lepidus led to the demise of the second triumvirate

in 31 BCE. In this year, Octavius defeated his rivals at the

Battle of Actium and assumed total control of the Roman

empire. 22 From this point on, Octavius skillfully played

the political game, nominally declining heightened status

while also consolidating his power. In 27 BCE, Octavius

announced his retirement to the Senate. The Senate refused

to accept this seemingly humble gesture, instead

giving Octavius the title Augustus, “one worthy of honor”

23 . The Senate also granted Augustus proconsular powers,

giving him complete control of the army. 24 Essentially,

19 Ramage, Edwin S. “Augustus’ Treatment of Julius

Caesar.” Historia: Zeitschrift Für Alte Geschichte 34, no. 2

(1985): 224 http://www.jstor.org/stable/4435922.

20 Scott, Kenneth. “Emperor Worship in Ovid.” Transactions

and Proceedings of the American Philological Association

61 (1930): 50. doi:10.2307/282793.

21 Nguyen, Minh-ah. “Augustus and His Agenda.”


23 Ibid., 33.

24 Wegen, P. van. “Augustus and the Principate. The

Transformation from Republic to Empire: The Unique

Properties of the Principate.,” 2012, 20. http://dspace.

library.uu.nl/handle/1874/250362.

102

Augustus orchestrated an endorsement of his new empire

by agents of the old Roman republic.

Once in power, Augustus embarked upon an ambitious

moral and military program. Dismayed by the state

of Roman morality, Augustus hoped to restore the values

of the Roman Republic. 25 Soon after receiving proconsular

powers, Augustus instituted a series of marriage and family

laws. 26 However, these reforms faced widespread opposition,

and Augustus abandoned the program. Following

this, Augustus focused on military campaigns. In his autobiography

Res Gestae, Augustus boasts that he “subjected

the world to the empire of the Roman people” 27 . Augustus

celebrated his victories by placing statues throughout the

empire. 28 Indeed, Augustus of Primaporta’s primary purpose

was celebrating Augustus’ victory over the Parthians.

Romans and Parthians had long been enemies. Though

embarking on many campaigns against the Parthians, the

Romans suffered defeat each time. But around 20 BCE, Augustus

engineered a victory via diplomacy, and ushered

in the Pax Romana. 29 Upon this victory, Augustus revisited

his moral program. Acting as pater patriae, father of the

country 30 , Augustus all but compelled marriage between

Roman men and women of specific ages. A number of political

and financial incentives corresponded to the number

of children produced by a respectable Roman marriage. 31

Thus, Augustus embarked upon a strict moral campaign

in order to transform the face of the Roman empire.


26 Frank, Richard I. “Augustus’ Legislation on Marriage

and Children.” California Studies in Classical Antiquity

8 (1975): 43. doi:10.2307/25010681.


28 Ibid., 138.

29 Pollock, Alex. “Roman Propaganda in the Age of

Augustus.” Dominican University of California, 2017, 17.


and Children.”, 8


and Children”, 44.

103

Because of these military and diplomatic efforts, a

cult of personality emerged for Augustus. Augustus practically

weaponized popular support in order to obtain

military power. 32 With careful use of propaganda, Augustus

maintained the illusion that Rome was a Republic. 33

Augustus referred to himself as princeps, or “leading citizen”.

34 Others referred to him as pater patriae. Rarely, if at

all, did Augustus openly declare his actual status among

Romans. Most Romans were illiterate, so visual propaganda,

such as Augustus of Primaporta, proved particularly potent

in maintaining this illusion. 35 Later leaders, including

Napoleon, Mussolini, and even Joseph Stalin, used similar

tactics to promote themselves and their country.

Indeed, Stalin is significant in the study of Soviet

Worker and the Collective Farm Woman. Though not the

founder of the USSR, Stalin proved a major figure in its

rise to world power. The early years of the USSR were

turbulent, to say the least. In The October Revolution of

1917, the Bolsheviks seized power under the leadership

of Vladimir Lenin. 36 However, opposition persisted for

most of the 1920s. Throughout this period, Lenin maintained

singular interest in consolidating power. 37 Lenin’s

influence persisted even after his death in 1924. A cult of

personality memorialized Lenin, and inspired his followers.

After Lenin’s death, Trotsky and Stalin emerged as

competing heirs. 38 Though their conflict predated Lenin’s

32 Ibid.

33 Ibid., 11.

34 Ibid., 10.

35 Ibid., 16.

36 Ibid., 27.

37 Felshtinsky, Yuri. “Lenin, Trotsky, Stalin and the

Left Opposition in the USSR, 1918-1928.” Cahiers Du

Monde Russe 31, no. 4 (1990): 570 https://doi.org/10.3406/

cmr.1990.2251

38 Goldern, James von. “Death of Lenin.” Seventeen

Moments in Soviet History, June 17, 2015. http://soviethistory.msu.edu/1924-2/death-of-lenin/.

104

death, 39 Trotsky and Stalin became especially opposed to

each other after 1924. 40 Much like Augustus had capitalized

on the deification of his predecessor Caesar, Trotsky

and Stalin capitalized on the all-but-deification of Lenin. 41

Trotsky increasingly found himself isolated, partly due to

his abrasive nature and partly due to the efforts of Stalin. 42

Stalin’s lust for power, and his brutal methods of obtaining

it, are well documented. 43 In 1929, Stalin permanently

expelled Trotsky from the USSR. With this, opposition of

the 1920s ended. Stalin was in control. 44 Stalin, like Augustus,

carefully undermined his opposition before assuming

complete control.

As in Rome, the newly-formed USSR saw efforts

to revise family law. After the Bolsheviks seized power, a

series of laws attempted to essentially abolish the family

as a meaningful unit. Child rearing would be collectivized

rather than the duty of individual families. 45 These efforts

failed, and later family law treated the family as an agent

of social control. Due to World War I, famine, and Stalin’s

purges, the birth rate in the USSR had dramatically decreased.

46 Though earlier family law codes had simplified

divorce and abortion, 47 law codes of 1934-1936 responded

39

40 Felshtinsky, Yuri. “Lenin, Trotsky, Stalin and the

Left Opposition in the USSR, 1918-1928”, 572.

41 Ibid.

42 “Communism: Karl Marx to Joseph Stalin.” CES

at UNC. Accessed July 6, 2019. https://europe.unc.edu/

iron-curtain/history/communism-karl-marx-to-joseph-stalin/.

43 Huesken, Gerald. “The Rise of Stalin in the USSR.”

Elizabethan Area School District, 2019, 21.

44 Felshtinsky, Yuri. “Lenin, Trotsky, Stalin and the Left Opposition

in the USSR, 1918-1928”, 574.

45 Glass, Becky L., and Margaret K. Stolee. “Family

Law in Soviet Russia, 1917-1945.” Journal of Marriage and

Family 49, no. 4 (1987): 893. doi:10.2307/351982.

46 Ibid.

47 Ibid.

105

to the birth rate crisis by discouraging promiscuity and

outlawing nonmedical abortion. These new codes emphasized

the traditional family as an “instrument of social

control”. 48 Thus, like Augustus, Stalin oversaw efforts to

manage society with family law.

Furthermore, Stalin, like Augustus, fostered a cult

of personality. Though “Stalinism” peaked in the late

1940s, it tremendously influenced art in the 1930s. 49 In

1932, Stalin named Socialist Realism the only acceptable

style of art. 50 Such art would educate the masses on the

philosophy of socialism and glorify the proletariat’s efforts

to achieve social progress. 51 In sum, art constituted a convenient

way to promote the greatness of the Soviet state.

Art became a mask for an aggressive political agenda.

It was in these contexts that Augustus of Primaporta

and Soviet Worker and the Collective Farm Woman emerged.

The similarity of these contexts is perhaps startling. Stalin,

like Augustus, capitalized on the influence of his predecessor

in order to overcome a political foe and manipulated

family law to accomplish his political agenda. Both Stalin

and Augustus encouraged a cult of personality in their

efforts to consolidate power. Augustus was perhaps more

subtle in his consolidation of power; after all, he did declare

his retirement to the Senate. However, his sincerity

in this action is highly debatable. Overall, then, Augustus of

Primporta and Soviet Worker and the Collective Farm Worker

emerged from similar historical contexts.

Both statues also used contemporary techniques

and imagery to exalt their subjects. Augustus of Primaporta

exhibits technical advances of the Greeks, namely,

contrapposto and the Canon of Polykleitos. Essentially,

a figure in contrapposto stands with one leg straight and

48 Ibid.

49 Mawdsley, Evan. The Stalin Years: The Soviet Union,

1929-1953. Manchester University Press, 1998, 58.

50 “Art and Ideology: Late 1920s–1940s.” Guggenheim,

August 26, 2010. https://www.guggenheim.org/arts-curriculum/topic/art-and-ideology.

51 Ibid.

106

the other bent. 52 Contrapposto heightens the realism of a

figure by giving it the potential to move. This constituted

a considerable technological advancement in Greek art.

The Greek sculptor Polykleitos incorporated this technique

in his “Canon of Polykleitos”, which described the

rules for creating an ideal human figure. 53 Augustus of

Primaporta exemplifies these rules. Augustus’s right leg is

straightened, while his left leg bends. This gives the illusion

of motion in Augustus. Combined with his gesture of

adlocutio, Augustus appears to be dynamically speaking

to the masses. In accordance with the Canon, Augustus is

well proportioned and counterbalanced. 54 In addition, the

statue is based on Polykleitos’ Spear-Bearer, 55 which exemplifies

the Canon of Polykleitos. 56 As a result, Augustus of

Primaporta harkens back to the perfection of Polykleitos.

The statue subtly sends the message that Augustus constitutes

the ideal man.

Soviet Worker and the Collective Farm Woman likewise

used contemporary technology. By 1937, the USSR

had finished a period of rapid industrialization. 57 Prior to

this, the USSR had fallen far behind the Western world in

industrialization. 58 Thus, upon mastering the techniques

of steel, Russian artists were eager to use it to promote

Socialist Realism. This sculptural group also seems to

draw from Classical Greek techniques. The figures exhibit

contrapposto, as their legs are alternately relaxed

52 Stokstad, Marilyn, et. al. Art History, 1140.

53 Ibid., 134.

54 Ibid.

55 Moon, Warren G., and Barbara Hughes Fowler.

Polykleitos, the Doryphoros, and Tradition. Univ of Wisconsin

Press, 1995, 272.

56 Stokstad, Marilyn, et. al. Art History, 134.

57 Glass, Becky L., and Margaret K. Stolee. “Family

Law in Soviet Russia, 1917-1945”, 898.

58 Wolanski, Molly. “The Role of Women in Soviet

Russia.” Boston University. Accessed July 1, 2019. https://

blogs.bu.edu/guidedhistory/moderneurope/molly-wolanski/.

107

and engaged. Indeed, the group seems to expand upon

this Greek technique. Contrapposto originally suggested

movement. In Soviet Worker and the Collective Farm Woman,

contrapposto outright shows movement. Thus, the Roman

and Russian sculptures both exhibit careful use of contemporary

techniques.

Furthermore, both Augustus of Primaporta and Soviet

Worker and the Collective Farm Woman use classical and

religious imagery. Augustus of Primaporta primarily uses

classical Greek motifs, and only sparingly uses Hellenistic

details. Just as Stalin favored a specific style, Augustus

preferred a specific style drawing heavily from classical

work. Emotional Hellenistic tendencies only appear in the

dynamic scene of surrender on the breastplate. 59 The scene

on the breastplate also carefully uses religious imagery to

establish Augustus’ cosmic importance. The gods watch

the Parthian king hand over his standard. 60 It appears

that the victory of Augustus is the will of the gods. 61 A

sculpture of Cupid, son of Venus, reminds the audience of

Augustus’ divine heritage. Augustus strove to be the ideal

Italian man, particularly after his enemies sneered at his

Italian origins. 62 The addition of Cupid states that the gods

endorsed the Italian Augustus. His heritage should not be

mocked. Thus, the statue uses classical motifs to promote

the message of Augustus’ superiority.

Similar classical and religious imagery appears in

Soviet Worker and the Collective Farm Woman. When designing

the statue, Vera Mukhina found inspiration in

The Tyrannicides. 63 The classical sculpture commemorates

Aristogeiton and Harmodius, who in 514 BCE killed the

brother of the Athenian tyrant Hippias. They failed to kill

Hippias himself and were subsequently executed. Howev-

59 Stokstad, Marilyn, et. al.. Art History, 172.

60 Edmondson, Jonathan. Augustus, 303.

61 Ibid., 18.


and Children”, 49..

63 “The Tyrannicides”, marble, 2nd century CE, National

Archaeological Museum, Naples.

108

er, the civic loyalty of Aristogeiton and Harmodius earned

them posthumous fame. 64 This story perhaps inspired

Soviet artists. Just as Aristogeiton and Harmodius fought

the tyranny of Hippias, Soviet citizens fought the tyranny

of capitalism. In any case, the physical similarities between

The Tyrannicides and Soviet Worker and the Collective Farm

Woman are striking. In both, two figures stride forward

side-by-side, lifting their arms, holding agents of change.

Harmodius holds a sword, while Mukhina’s figures carry

a sickle and hammer. Thus, Mukhina adapted the inspiring

classical tale for her era. This classical inspiration gives

a sense of dignity, legitimacy, to Soviet Worker and the Farm

Woman, and advances its message.

In her sculpture, Mukhina also skillfully used religious

motifs to further advance her message. While Augustus

supported Roman religion and even molded it into

a sort of imperial cult, 65 Stalin all but outlawed religion. 66

However, religious motifs in this sculpture attract peasant

workers to Socialist Realism. Like Augustus of Primaporta,

the sculpture group is larger than life. Lenin had promoted

such monumentalism that harkened back to religious

iconography of early Russia. 67 This practice remained under

Stalin, and Socialist Realist art of the 1930s drew from

religious iconography to broaden its appeal. For example,

the sculpture group rises vertically, much like a cathedral.

It stands so high above the average viewer that a sense

of the supernatural is practically inevitable. 68 In addition,

64 Smith, Amy C. “Athenian Political Art from the

Fifth and Fourth Centuries BCE: Images of Historical Individuals.”

Dēmos: Classical Athenian Democracy, The Stoa:

a consortium for electronic publication in the humanities,

January 18, 2003. http://www.stoa.org/projects/demos/article_portraits?page=7&greekEncoding=UnicodeC.


66 Huesken, Gerald. “The Rise of Stalin in the USSR.”

Elizabethan Area School District, 2019, 34.


from Propaganda to Nostalgia”, 3.

68 Ibid.

109

the flowing drapery of the two figures suggests wings.

These elements suggest that Stalin’s society, headed by the

proletariat, will replace religion. Thus, much like Augustus

of Primaporta, Soviet Worker and the Collective Farm Woman

harnesses classical and religious imagery to support its

message.

Thus, both statues have similar historical backgrounds

and utilize skillful techniques and imagery. They

employ older artistic methods in order to propagate a new

political message. However, the precise political message

propagated differs in each statue. Augustus of Primaporta

exalts a man who built a society, while Soviet Worker and

the Collective Farm Woman exalts a society and its people.

First, consider Augustus of Primaporta. This statue

was created to celebrate Rome’s victory over the Parthians.

However, the only visible soldiers appear on Augustus’

breastplate. Indeed, the statue depicts Augustus alone.

This suggests that Augustus of Primaporta primarily exalted

the leader of the Roman empire. The statue originally

stood in a private villa owned by Livia, Augustus’ wife. 69

However, Augustus commonly celebrated his victories by

placing statues throughout the empire. 70 Copies of Augustus

of Primaporta likely appeared throughout the empire in

order to spread its narrative.

Spreading Augustus’ narrative was crucial for

maintaining his cult of personality, for the actual victory

over the Parthians differed from the narrative presented in

Res Gestae and Augustus of Primaporta. Augustus actually

managed this victory with more diplomacy than raw

might. However, Res Gestae and Augustus of Primaporta

both present it as a military victory. 71 Augustus wears

military garb, but stands calmly, suggesting that he easily

accomplished this significant victory. He appears in the

69 Paolinelli, Marcie Collin. “A Visitor’s Guide to the

Villa of Livia at Prima Porta.” California State University,

2012, 1.


71 Pollock, Alex. “Roman Propaganda in the Age of

Augustus”, 17.

110

prime of life, strong, ready to fight again. This Augustus

was no mere negotiator, but a soldier with divine approval.

Yet Augustus adopts the pose of the orator, suggesting

that he was a member of the Senate rather than dictator.

This curious combination of roles presents Augustus as a

formidable leader, one capable of great power yet willing

it to the people. Of course, Augustus really had consolidated

power by this point. But his presentation as first citizen

rather than emperor made him an admirable leader for the

Romans. In Rome, the manipulation of narratives constituted

a common form of propaganda. Statues proved a

simple way to promote this narrative, especially among

the illiterate. 72

From these items, it seems that Augustus of Primaporta

primarily exalted the leader and his society. Augustus

is pictured as a mighty, yet composed, hero. No other

soldiers appear besides the few in the breastplate relief.

Thus, the viewer’s immediate focus is the great figure

Augustus. A small sculpture of Cupid emphases his divine

heritage, and the gods express their approval of his work.

Augustus did not fully pursue his social program until he

accomplished military victory. Indeed, he faced a great

deal of opposition in earlier attempts to redesign family

law. Thus, the statue might have been a way to declare

Augustus’ military greatness, so that he could continue to

enact his social program.

Soviet Worker and Collective Farm Woman, on the

other hand, exalts a society and its men. Of course, the

sculptural group reflected on Stalin and tacitly declared

his greatness. But the group ostensibly only declared the

superiority of the USSR. For Soviet Worker and the Collective

Farm Woman was created for the 1937 World’s Fair. This

was the first World’s Fair to which the USSR had received

an invitation, and as a result, their exhibition held considerable

importance. 73 After all, their pavilion practically

72 Ibid., 3.

73 Yegorov, Oleg. “5 Facts about ‘Worker and Kolkhoz

Woman’ – an Incredibly Troublesome Soviet Statue.”

Russia Beyond, November 9, 2017. https://www.rbth.com/

111

equaled a presentation to a foreign audience, and could

serve as an important advancement of Soviet ideology. 74

The theme of the World’s Fair was “art and technology

in the modern world”. 75 Having only recently

industrialized, the USSR hoped to showcase its technological

advances. Furthermore, Nazi Germany had also been

invited, and their pavilion 76 stood directly opposite of the

Soviet pavilion. The 1937 World’s Fair, then, staged a

showdown between two competing ideologies. A Russian

newspaper from 2016 still comments on the superiority

of USSR ideology to Nazi ideology, stating, “our pavilion

turned out to be higher than the fascists’ (which was

fundamentally important!)”. 77 Clearly, leaders of the USSR

were motivated to use their pavilion to advance ideology

rather than specific figures.

Vera Mukhina won a state-sponsored competition,

and designed Soviet Worker and the Collective Farm Woman

for the Soviet pavilion. Notably, this statue idealizes USSR

society under Stalin rather than promoting Stalin himself.

It was not supposed to be realistic; it was supposed to

glorify the present and promote the future. 78 Two figures

represent the USSR, including a peasant woman. Over the

first two decades of the USSR, the peasant woman came to

be a carefully cultivated image. Posters in the early 1930s

used images of the peasant woman to promote collectivization.

In these, women were typically depicted as enarts/326672-worker-and-kolkhoz-woman.


from Propaganda to Nostalgia”,12,

75 Рыков, Сергей. “Как Корреспонденты Искали

Профиль Троцкого На ‘Рабочем и Колхознице.’”

Российская газета, September 14, 2016. https://rg.

ru/2016/09/14/reg-cfo/kak-korrespondenty-iskali-profil-trockogo-na-rabochem-i-kolhoznice.html.

76 Ibid.

77 Ibid.

78 Victoria Bonnell, “The Peasant Woman in Stalinist

Political Art of the 1930s,” 82.

112

gaged in agricultural labor. 79 The woman in Soviet Worker

and the Collective Farm Woman holds a sickle, a reference to

agriculture, above her head. It almost seems as if a collectivization

poster has come to life. The man wears the garb

of a blacksmith, declaring his membership in the proletariat.

Soviet Worker and the Collective Farm Worker originally

stood near a mirror pond, which multiplied the image of

the determined pair. 80 Viewers could join the sculptural

pair, and enter into the masses of the glorious proletariat.

Thus, the Soviet Worker and Collective Farm Woman’s primarily

worked to glorify Stalin’s USSR.

The dissemination of Soviet Worker and Collective

Farm Woman further exhibits its use as a tool to extend

USSR propaganda. Throughout the Stalin era, the statue

was widely reproduced. It also appeared in postcards

and in the background of films, subtly promoting USSR

ideology through a variety of mediums. As an excellent

encapsulation of Soviet ideology, the sculptural group

could declare to a variety of audiences the glory of the

USSR. Kojoyan argues that the statue’s appearance in

theater, songs, and film comprise one of the most efficient

examples of modern propaganda. 81 Clearly, Soviet Worker

and the Collective Farm Woman worked to promote a society

rather than a single man. It glorified the USSR and its

working class. It declared to the world the superiority of

Stalin’s ideology.

Art certainly comprises a potent form of propaganda.

By draping a political message in the trappings of

grandeur, political leaders can effectively propagate their

programs. Augustus of Primaporta and Soviet Worker and the

Collective Farm Woman demonstrate this realization. These

two statues, though separated by some two thousand

years, emerged from similar historical contexts and employed

similar techniques. Both Augustus and Stalin, who

79 Ibid., 63.

80 Рыков, Сергей. “Как Корреспонденты Искали



from Propaganda to Nostalgia”,13.

113

oversaw the construction of these statues, undermined

competing political leaders before decisively consolidating

power. They used this newfound power to enact a

series of family regulations, in hopes of transforming their

respective countries. They also used artwork to promote

their interests. Augustus of Primaporta exalts Augustus, the

man responsible for the glorious Roman empire. Classical

and religious motifs enhance the legitimacy of this statue.

Soviet Worker and the Collective Farm Worker uses similar

techniques, but highlights the society of the proletariat.

The specific purposes of these statues, then, differ significantly.

Nonetheless, Augustus of Primaporta and Soviet

Worker and the Collective Farm Woman underscore the power

of art. An exposed propaganda program may appear

insidious, but once draped in grand art, whether it be of

stone or steel, it more easily enters cultural discourse.

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118

OUTSTANDING UPPERCLASSMAN SUBMISSION

Orientalism and the Construction of the Victorian

Identity in Arthur Conan Doyle’s Sherlock

Holmes series

Amber Gaudet

The first novel of Arthur Conan Doyle’s Sherlock

Holmes detective series, A Study in Scarlet, appeared in

Beeton’s Christmas Annual in 1887. At the height of the

Victorian era, the tale of a clever English detective facing

off against strange maladies and dangerous foes - often a

product of the exoticisms of the East – was well-received

in the rapidly expanding British empire. With increasing

territory came increasing exposure to new cultures,

however, creating anxieties in imperialist England about

the invading values of foreign lands. Without English

imperialism, Doyle’s Holmes adventures would not have

risen to the height of popularity that they did in the late

19th century. Doyle both played off and was a product of

Victorian anxieties about a cultural invasion, reinforcing

the use of otherism to validate British culture and British

models of progress and civility.

Victorian beliefs about the superiority of British

civilization to other cultures is a widely recorded fact. English

citizens’ confidence that they were the smartest, most

civilized and advanced race of people was necessary to

allay guilt over the cruelties of colonization by viewing the

practice as their responsibility. “The often-brutal effects of

colonial domination were rationalized by a pseudo-science

purporting to demonstrate the inferiority of dark-skinned

peoples and by a keenly felt, much-encouraged sense of

racial and cultural superiority over other peoples” (Broadview

Anthology of British Literature 510). The “white

man’s burden,” as it was coined by Rudyard Kipling,

meant that any mistreatment of the colonized was excusable,

as was the decimation of their inferior culture. The

English regarded it as their unique responsibility to tame

as many “savages” as possible through the expansion of

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the British empire.

The rise of the novel itself, particularly genre fiction,

was also a result of England’s expanding empire in

the Victorian era, making Holmes’ popularity possible.

Increases in technology popularized train travel, including

to faraway places like India.

So important was the advent of railway travel to

the development of English daily life, railway stations

even became essential to the book trade and the spread of

leisure reading; from the 1850s onward, book stalls catering

to thousands of daily commuters began to stock their

shelves with newspapers, magazines, and cheap, popular

fiction, which became known as ‘railway literature.’ (Black

et al., 525)

Without these long journeys, the novel may not have risen

in popularity as it did during the Victorian era, situating

the Holmes cannon squarely within late 19th century England.

Also evident in the rise of both popular novels and

travel narratives, particularly toward the end of the century,

is Britain’s obsession with the exotic other. Though

support in England for imperialism grew during this

period, it did so at a rate in opposition to the strength of

the empire, whose foothold was beginning to slip from

the world stage. “The imperial romances of some authors

were a symptom of the anxieties surrounding Britain’s increasingly

tenuous grip on its empire. Whereas early and

mid-century Victorian fiction tended to imagine the Empire

as a fairly static, unknown space to which characters

can be exiled in the interests of narrative closure, late-century

fiction often represented the Empire in darker, Gothic

terms” (Broadview 514). While the British were filled with

self-assurance as to their place as the guardians of cultural

and social refinement earlier in previous decades, a

changing sociopolitical landscape and evolving views on

race relations threatened England’s position as the world’s

greatest power.

The influence of imperialism in Doyle’s Holmes

tales, however, was significant even within the Victorian

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era. Doyle achieved immense popularity in the last two

decades of the Victorian era, allowing him to quit work

as a doctor and write full-time. Doyle wrote many short

stories and three of the four Holmes novels during this period:

The Sign of Four in 1890, The Adventures of Sherlock

Holmes in 1892, and The Memoirs of Sherlock Holmes in

1894. These last two decades of the 19th century were also

the height of British imperialism. “In England, popular

support for the Empire reached its zenith in the 1880s and

1890s as Britain accelerated the pace of its drive to increase

its imperial acquisitions to compete with other European

powers and with the United States” (Broadview 512). As

imperialism intensified so too did the need for reassurance

of Britain’s place in the world and its responsibility to

“less-developed” cultures, a reassurance that readers no

doubt found in Sherlock Holmes.

Thus, as telling as the orientalism in the Holmes

tales during the Victorian era is, what’s even more revealing

is its absence in the works produced after 1901. Using

anthropological themes, Doyle reinforced popular ideas of

hereditary-racial superiority in the Victorian fin de siècle,

a unique set of social concerns prevalent during the end

of the Victorian era of rapid imperialism (McNabb 728). In

Doyle’s 1886 adventure, A Study in Scarlet, Watson references

Drebber’s “baboon-like countenance” of “the most

malignant type” (Doyle 26) (as quoted by McNabb 734)

reflecting atavistic philosophies popularized by Victorian

anthropologist Francis Galton. Galton’s theory on inheritance

posited that abnormal traits such as being remarkably

tall or short would regress to “normalcy” after several

generations (McNabb 735). Doyle readily applied Galton’s

theories to criminality, propagating the idea that criminal

deviancy was a result of inherent, hereditary traits prevalent

among the “exotic.”

In perpetuating these beliefs, Doyle often associated

illicit drug use with the East. In The Sign of Four, Holmes’

encounter with the case of Mary Morstan and the Indian

thieves, is linked to Holmes’ drug use.

In disapproving of the drugs Holmes uses, Watson

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speaks within the context of ongoing medical debates

about opium, morphine, and cocaine, all seen as narcotics

and popularly if wrongly associated with ‘opium

eating.’ Both the late-Victorian physician and the general

public perceived such addicting drugs as contaminations

emanating from alien and primitive lands. […] Watson’s

disapproval simply furthers the mythology that identified

cocaine and morphine as a threat to all things British,

rational and moral. (Frank 58)

In this and countless other scenes, Doyle associates

English corruption with the influence of exotic lands,

linking the foreign with the treacherously tempting in

ways that reinforce English perceptions of different races

as primitive and amoral.

Similarly, Doyle’s tendency to draw connections

between ideas of the invasive and the exotic to reinforce

prejudice is not limited to drug use. Doyle uses maladies

as metaphors for English anxieties about how contact with

foreign (non-white) nations might change English society

for the worse, likening “barbarism” to something contagious.

Mrs. Hudson first describes Holmes’s illness as

a typical contagion he “brought... back with him” from

an unhealthy part of town (386). When Watson visits

Holmes’s sickroom he finds the tool Culverton Smith intended

to use to infect Holmes - an ivory box concealing a

spring like ‘a viper’s tooth’ (399) - and the disease becomes

both a poison and a weapon, transmitted by this device

identified with Africa (ivory) and Asia (home of the “Indian

swamp adder,” the other “viper” that figures prominently

in the Holmes canon). (Harris 448)

Not only does Doyle use diseases and poisons supposedly

of foreign origin to associate the exotic with the

unclean, but he also uses them as a metaphor for the cultural

invasion he feared. By doing so, Doyle can construct

Holmes’ persona and paint him in a moral and rational

light. Through Holmes, a pop culture hero of the era Doyle

demonstrates that although Eastern-culture-as-contagion

is invasive and catching, it is also containable given the

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detective’s unique set of logic, intellect, and worldliness

(Harris 448). Considering the English’s view of themselves

as intellectually superior to foreign nations, Doyle’s metaphor

and the English Holmes-as-savior was particularly

effective at easing the anxieties that Doyle himself fed.

Doyle’s construction of Holmes was related to his

interest in anthropology and his thoughts on increased

exposure to foreign cultures brought about by England’s

expanding empire. “Doyle believed that national difference

should be abandoned in favor of racial unity and

that England and America should become one nation.

[…] He was one of many avid supporters of a movement

that clamored for Anglo-American reunion and the federation

of the Anglo-Saxon race” (Thomas 2001). Doyle’s

belief that race made whites superior even prompted him

to advocate for the renunciation of British citizenship

and immigration to America if it meant the unification of

Anglo-Saxons (Thomas 2001). This belief manifested in

interest in emerging anthropological and ethnographical

theories that supported the idea that race was linked with

ability, intelligence, and character. In The Sign of Four,

Doyle employs his interest in Indian ethnography – which

“set racial, caste, and tribal types in authoritative taxonomies

[via] the Indian census” (McBratney 153) – in his

descriptions of the Andaman Islanders (McBratney 154).

They are naturally hideous, having large, misshapen

heads, small, fierce eyes, and distorted features. Their

feet and hands, however, are remarkably small. So intractable

and fierce are they, that all the efforts of the British

officials have failed to win them over in any degree. They

have always been a terror to shipwrecked crews, braining

the survivors with their stone-headed clubs or shooting

them with their poisoned arrows. These massacres are

invariably concluded by a cannibal feast. (Doyle 127-28;

ch.8) (as quoted by McBratney 154)

In this passage and the many like it in the Holmes canon,

Doyle solidifies Victorian tropes of the white savior and

the corrupt foreigner, advancing his perceptions of white

supremacy.

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Doyle’s metaphor of foreigner-as-invader is perhaps

equally as apparent in his telling descriptions of England.

In A Study in Scarlet, Doyle describes England’s bustling

capital and the hub of imperial progress, as a place being

overrun by outside waste.

Laura Otis has recently noted that Doyle thus establishes

both London and Watson as imperial bodies “under

siege.” Watson’s metaphor is certainly one of invasion:

the capital is a “pool” into which contaminated colonial

waterways flow and introduce sepsis. And Watson’s own

body has also been invaded: a Jezail bullet has pierced the

soldier-surgeon’s shoulder, leaving him with a shattered

bone, a grazed artery, and, most damagingly, “shaken

nerves” (19). (Thomas)

In painting London as a town “under siege,” Doyle further

supports his belief that country is based less on geography

and more on race and values. In doing so, Doyle asserts

perceptions of white Westerners as the elite ruling class of

the Victorian world being threatened by the distant, yet

invasive, nature of their subjects.

Doyle is certainly no outlier in his field; as is widely

documented, perhaps most famously by Edward Said in

Orientalism, British thinkers juxtaposed the customs of

foreign cultures against the “moral uprightness” of Victorian

society. Closely tied with these conceptions of morality

was Christianity. “In Orientalism, Edward Said summarizes

the dialecticism of the reliance of Orientalism on

Christianity to establish the image of an immoral East, and

Christianity with Orientalism to supply it with the need

to moralize the world, by stating that ‘the Orient accommodated

to the moral exigencies of Western Christianity’

(67). In other words, in order for such a cultural discourse

to function, the prejudicial image of an irreligious and

barbaric other – the Orient – is essential to the affirmation

of the virtuous and civilized Victorian cultural identity”

(Yue 1). Holmes, the white savior, can be the champion of

Anglo-Saxon, Victorian culture, only through his defeat of

the corrupted other and would have been less pacifying

to readers who shared Doyle’s anxieties about growing

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empire had he been battling home-bred enemies.

Holmes villains who were English had, of course,

had associations with or been corrupted by the East. In

Doyle’s 1892 short story, “The Adventure of the Speckled

Band,” the antagonist Dr. Roylott, had worked in India

as a doctor, marrying Helen Stoner’s mother there (Doyle

970). After returning to England, Roylott maintains ties

with the barbaric East, terrorizing his good English neighbors

with exotic beasts (971). “He has a passion also for

Indian animals, which are sent over to him by a correspondent,

and he has at this moment a cheetah and a baboon,

which wander freely over his grounds, and are feared by

the villagers almost as much as their master” (Doyle 971).

The murder weapon itself was an Indian swamp adder,

able to kill its victims within ten seconds of biting them

(982). So, too, is Roylott’s white morality sullied by his associations

with gypsies, an ethnic group “believed to have

arrived in Europe from northern India in the 1400s” (United

States Holocaust Memorial Museum, n.d.). Contrasted

against the cultural purity of one of the richest and noblest

English families, Roylott is clearly a product of the corruption

that allegiance with non-white races breeds.

Doyle’s Sherlock Holmes series was a unique product

of the Victorian era that bore a direct relationship to

Britain’s expanding empire. Doyle, like many Victorians,

was anxious about what he perceived would be the ill

effects of exposure to other, “lesser” cultures. By associating

non-white foreigners with crime, illicit drug use, and

contagion, Doyle strokes Victorian anxieties in the late

19th century. The Holmes canon reflects Doyle’s allegiance

to the concept of an Anglo-Saxon nation, which he believed

was necessary to combat the growing decimation of

white Western culture. In feeding Victorian anxieties and

advancing his political and ethnographic beliefs, Doyle

creates the white savior in Holmes, constructing his identity

by juxtaposing it against the failings, both moral and

intellectual, of his savage adversaries. In this way, Doyle

is complicit in – and evidence of - the Orientalism that

Victorians used to construct and validate their identities,

125

situating his adventure novels in the fear and possibility of

expanding empire that defined the Victorian era.

Works Cited

Black, Joseph et al., editors. The Broadview Anthology of British

Literature, Broadview Press, 2013.

Frank, Lawrence. “Dreaming the Medusa: Imperialism,

Primitivism, and Sexuality in Arthur Conan Doyle’s ‘The

Sign of Four.’” Signs, vol. 22, no. 1, 1996, pp. 52–85. EB-

SCOhost, search.ebscohost.com/login.aspx?direct=true&db=lfh&AN=9704185388&site=ehost-live.

Harris, Susan Cannon. “Pathological Possibilities: Contagion

and Empire in Doyle’s Sherlock Holmes Stories.”

Victorian Literature and Culture, vol. 31, no. 2, 2003, pp.

447–466. JSTOR, www.jstor.org/stable/25058636.

McBratney, John. “Racial and Criminal Types: Indian

Ethnography and Sir Arthur Conan Doyle’s ‘The Sign of

Four.’” Victorian Literature and Culture, vol. 33, no. 1, 2005,

pp. 149–167. JSTOR, www.jstor.org/stable/25058700.

McNabb, John. “Anthropology by Gaslight: Sherlock

Holmes, Conan Doyle and the anthropology

of detection at the Victorian fin de siècle.” World

Archaeology, vol. 49, no. 5, 2017, pp. 728-751, doi:

10.1080/00438243.2017.1406396

Thomas, Katie-Louise. “Racial Alliance and Postal Networks

in Conan Doyle’s ‘A Study in Scarlet.’” Journal of

Colonialism and Colonial History, vol. 2 no. 1, 2001. Project

MUSE, doi:10.1353/cch.2001.0017

“Who Were the ‘Gypsies’?” United States Holocaust Memorial

Museum, www.ushmm.org/learn/students/learning-materials-and-resources/sinti-and-roma-victims-of-the-naziera/who-were-the-gypsies.

Accessed 5 May 2019.

Yue, Isaac. “Missionaries (MIS-)Representing China:

126

Orientalism, Religion, and the Conceptualization of Victorian

Cultural Identity.” Victorian Literature and Culture,

vol. 37, no. 1, 2009, pp. 1–10. JSTOR, www.jstor.org/stable/40347210.

127

OUTSTANDING CAPSTONE 2019

Ups and Downs: A Documentary Exploring the

Oral Histories of Two Families with Children

who have Down Syndrome

Marisa Jean E. Patterson

Abstract

The lives of family members who have children with

Down syndrome often experience stressful situations

together, whether it be at the beginning when the child is

first born or possibly therapy or surgeries that may take

place in the child’s life. Through a documentary film the

oral histories of two families are used convey information

based on their personal experiences. Although their experiences

are not identical to all other families with children

who have Down syndrome, the

documentary film follows Hill’s ABC-X Model of Family

Stress and Coping by reflecting the stressors, perceptions

and resources experienced by these two families who had

a child with Down syndrome.

Keywords: Down Syndrome, Family, ABC-X Model of Family

Stress and Coping,

Introduction

One of the most common birth defects currently in

the United States is the chromosomal defect, Down syndrome.

Down syndrome is a chromosomal defect where

an individual having three chromosomes on the 21st

strand, resulting in developmental delays for the individual.

In the United States, births of children with Down

syndrome occurs in approximately 6000 births every year

(Presson, Partyka, Jensen, Devine, Rasmussen, McCabe &

McCabe, 2013). The presence of Down syndrome in a child

is shown through physical characteristics such as potential

dysmorphic facial features, broader hands, congenital

heart disease and hypotonia, as well as potential speech

difficulties, language impairments, and literacy difficulties

(Lyons, Brennan, & Carroll, 2016). The life expectancy for

128

individuals with Down syndrome has increased over the

past, therefore meaning that more individuals are living

with Down syndrome

currently than before. As like other children with disabilities,

Down syndrome results in adding additional stressors

to the family through areas like health care, child care,

school, social

participation, and more areas of life.

Although the lives of each individual family with

a child who has Down syndrome varies, taking an inside

examination of specific families to view their experiences

is helpful in understanding how the family with a special

needs child relates to Hill’s ABC-X model of family stress

and coping. “Ups and Downs” is a documentary that

explores the lives of two families with children with Down

syndrome. With the families discussing stressors that take

place in their lives, their personal perception on the stressor,

the resources that were utilized to adjust and cope to

the stressor, and the responses of the family, the viewer

is able to understand a little about the ABC-X model in

action through the narrative of the participants.

Literature Review

Reuben Hill describes the event of stress in a family

through the ABC-X model of family stress and coping. The

creation of Hill’s model was influenced by the concept of

how the family responds and reacts to situations of hardship

or change, also known as family resiliency (Rosino,

2016). Each variable in the ABC-X model represents a

different part during the experience of a stress or change

in the family. The model can be described as the variable

A representing the stressor or event that takes place in the

lives of the family, variable B representing the resources

that are provided to the family or the family finds available

in order to use as an aid for the response to the stressor,

variable C representing the family’s perception of the

stressor, which can be detrimental to the outcome of the

family’s resiliency from the stressor, and variable X representing

the amount of crisis that occurs after the stressor

129

has been introduced (Rosino, 2016). Hill also created the

double ABC-X model, which represents a pile up of stressors

in the families lives. When a family experiences multiple

stressors, the double ABC-X model comes into play

when examining the family and the child.

The first variable, A, in the ABC-X model begins

with the stressor or the stressful event that occurs within

the family. With Down syndrome being one of the most

common birth defects, it is estimated that it effects 14 out

of 10,000 live births in the United States (Marshall, Tanner,

Kozyr, & Kirby, 2014). Having a child is a stressor that

families go through, and when

the child has a disability, it can intensify the stress that is

added to the family. With further advances in technology,

medical professionals have the ability to do prenatal

screening, although expecting mothers often opt out of

such testing unless there are abnormalities shown early

on, thus approximating that 87.5% of diagnoses occur

postnatal (Marshall et. al, 2014). Areas of stress can

occur across a child’s lifetime and not only in infancy.

Parents experience stressors from the prenatal experiences

through the child’s school-age years, with intensity

focused on infancy and early childhood (Marshall et. al,

2014). Areas of stressors can include but are not limited to

the diagnosis and prenatal care, the services provided and

available, care co-ordination and service systems provided,

and the social and community support the family has.

The second variable, B, in the ABC-X model is resources

provided to or utilized by the family in response

to stressors. A study conducted by Cuzzocrea, Murdaca,

Costa, Filippello, &

Larcan (2016) demonstrates the differences found in the

parental stress across families with children who have

autism, Down syndrome, and typical developing children,

as well as the

difference in perception and resources that were used in

order to cope with the stressors. Families with children

with Down syndrome utilize the research provided to

come to the

130

conclusion that the coping strategy of social support is

used less than positive attitude and problem solving (Cuzzocrea

et. al, 2016). In terms of social support in a family

with Down syndrome, it was reported that parents of children

with Down syndrome had received similar amounts

of social support from family and friends when compared

to parents of children with

autism or typical developing children (Cuzzocrea et. al,

2016). Through social support and community support,

it is reported that the diagnosis of a child with Down

syndrome has a considerable amount of impact on both

the primary and extended family members as well as the

societal acceptance (Marshall et. al, 2014). Both of these

aspects can be potential stressors on a

family at first, but the social and community support

could ultimately be resources that aid the other stressors

that arise in the lives of a child with Down syndrome, such

as healthcare, childcare, and beginning school. Ultimately,

the stress added to a family raising a child with Down

syndrome is greater than a family who is raising a typical

developing child. This additional stress sometimes leads

to “poorer coping abilities” (Norton, Dyches, Harper, Roper,

& Caldarella, 2016). Another resource that is potential

in coping with rearing a child withDown syndrome includes

respite care. Respite care is the care that is provided

for a family member with Down syndrome in order to

give the parents, or permanent caregiver, a time of relief or

break (Norton et. al, 2016). One study shows that utilizing

the resource of respite care can have a positive impact in

the marital quality of parents of children with Down syndrome,

demonstrating that approximately 4% of husbands

and 10% of wives reported a distressed marriage, which

was significantly less than those of parents with children

with autism spectrum disorders (Norton et. al, 2016).

The third variable, C, in the ABC-X model is the

perception the family has about the stressor that occurs.

Although each family perception is different, there have

been studies done to find common perceptions that families

have on stressors that occur in a child’s life. A study

131

was conducted to view the parental perception on the

involvement of a child in everyday activities with typical

developing children, which can include school activities,

extracurricular sports, and more (Lyons et. al, 2016). Parents

placed value on the participation of their child with

other children and examined benefits from the participation

including “development of new skills, enhancing the

child’s well-being and a sense of belonging” (Lyons et. al,

2016). There is a lack of evidence regarding the parental

perception of the original diagnosis of a child with Down

syndrome, both prenatal and postnatal. Although studies

are not shown what the parental perception is, in America,

approximately 90% of prenatal diagnosis of Down syndrome

result in

the mother’s choice to abort the fetus (Shaw, 2018). While

this does not explain exactly the parental perception of

the diagnosis, this is the end result for the vast majority of

prenatal diagnoses. Studies also display that even though

technology is developing, there are risk factors

that go into prenatal screening, which results in mother’s

opting out of prenatal tests, thus not learning of the child’s

diagnosis until postnatal (Palomaki, Knight, Ashwood,

Best, & Haddow, 2013)

The last variable, X, of the ABC-X model is the family’s

response to the stress and whether or not it results in

a crisis. The availability of resources that are provided for

the family

and the perception the family has on the stressor are

what either makes the family thrive during the stressor

or ultimately crash. The family can either adapt to the

stressor, which is considered adaptation, adapt and be

more successful than before the crisis, which is considered

bonadaptation, or fail to adapt to the crisis fully, which is

maladaptation. Through studies, it is shown that in order

to have successful adaptation of a stressor on a family, the

child, social, and parental factors must interact (Sloper,

Knussen, Turner, & Cunningham, 1991). A family with a

child who has Down syndrome will experience multiple

stressors across the lifespan of the child, but the adaption

132

they have after each stressor will demonstrate the way the

family will succeed.

Rationale

Throughout the documentary, questions regarding

what a family goes through with a child who has Down

syndrome are answered through oral histories. The parents

answer questions regarding their own experiences

with their child, the stress that it has brought to the family,

and the resources they have used in response to the

stressors. The responses of the parents indicate how they

have perceived the stressor of having a child with Down

syndrome and the stress events that follow the birth of

the child. The answers provided from theparents in the

interview are not representation of all parents with children

who have Down syndrome but their personal experiences

may connect with other families with children who

have Down syndrome. Questions examined and explored

throughout the interview include, but are not limited to:

How has having a child with Down syndrome impacted

the parents and siblings?

What are stressors that are potential throughout the lives

of children with Down

syndrome?

What are resources that are beneficial to use during times

or after stressors have occurred in the lives of the family?

Method and Design

The documentary uses filmmaking techniques in

order to present information from research in a cinematic

fashion in order to display the stress on the American family

with a child

who has Down syndrome. Through the exploration of the

lives of the two families who are interviewed, a qualitative

research approach was taken in order to collect the data

and allow the

parents of children with Down syndrome to share their

voice. The results of the oral histories are to document

the experiences of two families with children with Down

133

syndrome and the

resources they used to adapt as a family to the stress

events that have occurred.

Sample. The exploration of the documentary involves

the lives of participants who have been chosen

based on purposive sampling. Three families with children

of different ages, different genders, and with and

without siblings were originally selected. Due to lack of

availability from one family, the decision was made to remove

them from the documentary process. The other two

participating families included two parents who have one

child, a daughter who is 10-years- old, and the other family

consisting of two parents who have three children, a

daughter at 20- years-old, a son at 9-years-old, and another

son at 6-years-old who has Down syndrome.

The Institutional Review Board did not review this

project since the collection of oral histories is not considered

human subjects research according to federal guidelines.

The

participants were given a list of questions that would

prompt their stories and the opportunity to abstain from

answering any questions that they did not want to. The

participants were able to remove themselves from the documentary

process at any time based on their own personal

discretion. All participants over the age of 18-years-old

involved in the documentary have given written consent

participate and be filmed and included in the documentary.

All family members under the age of 18-years-old have

given written permission by their legal guardian to participate

and be filmed and included in the documentary.

Media. The usage of documentary filmmaking

gives a cinematic design in order to demonstrate the

informational data collected. The documentary filmmaking

focuses on narratives of the participants in order to

convey information. Through the 20-minute documentary,

a combination between interview and b-roll footage, the

lives of the two families are displayed. The families were

given a choice to be interviewed and filmed in their own

homes, with or without their children accompanying them

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in the interview. The participants chose to be interviewed

in their own homes for reasons of comfort. The interviews

taking place in the homes of the participants

adds validity to the research provided by the participants

through their interviews. The b-roll footage was shot at

various times during various events that the family and

children participated in. One participant was filmed at

home, during herbirthday party, and at an event for families

with children who have Down syndrome through

the Down Syndrome Guild of Dallas. The other participant

only gave consent to be filmed in the home during

interview hours and one other time, no other events were

filmed due to participant consent.

The footage was all shot using a Canon 80d camera

across multiple events throughout a span of two months.

Upon completion of filming, the documentary was edited

through the software Adobe Premiere Pro CC 2019.

The filmmaking process utilizes the addition of a creative

method in order to display the informational data that

is collect through the study of interviewing participants.

The cinematic b-roll that is provided in the documentary

demonstrates authenticity and the everyday lives of the

children with Down syndrome and their family members,

such as their parents and siblings. Through the narratives

of the family member interview, as well as the narratives

of the participating children participating in everyday activities,

the viewer is able to visualize the lifestyle that the

family has, as well as possibly relate to the family through

the cinematic qualities of a documentary film.

Procedure

The filmmaking procedure for this qualitative study

began with the identification of the sampling through purposive

sampling. Once the families had been identified as

possible

participants in the documentary, they were contacted via

e-mail. After the consent was given for participation of

family members, the filming process began. The next step

was finding

135

coordinating times in order to interview for 1-2 hours

and gather footage. The families were given the decision

to be filmed in their own house or other locations of their

preference. Since the families had both chosen their houses

due to comfort levels, the footage began being filmed

during the first interview days. All forms of communication

with the families was done via Email. Upon filming

the interviews, the b-roll footage was gathered through

times at the interview and other times the family was

available, whether it be in the house again or at family

events (i.e. birthday party). Once the collection of interviews

was done and the b-roll was completely gathered,

the next step was the beginning of the editing stage. Upon

editing, the documentary was needing to flow as closely

as possibly to the pattern of Hill’s ABC-X Model of Family

Stress and Coping, the stress event occurs, the family’s

perception of the stressor and the resources that are used

and available, and the likelihood of another crisis forming

due to this one. Through this film format, it will make

it more understanding for the viewer to connect Hill’s

ABC-X Model of Family Stress and Coping to the informational

data that is shared through the

experiences of the participants in the documentary.

Results and Discussion

Through the qualitative study in the documentary

film, there are no results to analyze. The documentary

film, however, walks the viewer through the lives and

experiences of the two participating families and shows a

narrative in order to add the validity and reliability to the

research. The results of the narrative revealed information

regarding what the stressors are that a family with children

who have Down syndrome may experience from the

beginning of the child’s live, the birth, and throughout the

life as the child grows, including surgeries, therapies, and

school experiences.

In the study, the families revealed that stressful

events for them included the times they were told that

the child has Down syndrome. One family was told right

136

when the baby was born that the child had Down syndrome,

while the other family was told that there were

abnormalities during the pregnancy and had testing done

early on. The reactions discussed by the parents were very

genuine and displayed how most of the time. In terms

of the ABC-X Model of Family Stress and Coping, the

stressor event that occurs in the family is the birth and

knowledge of the child they are having or just had has

Down syndrome, something that was not planned at first.

The narrative of the reactions describes the perception the

family has on the stress event of having a child with Down

syndrome, and the resources were provided and sought

out are described by the parents in the interview. The

parent’s responses to the resources that were provided

and sought out were very similar, describing the overall

best resource they have utilized during stress events as the

friendships they have built with other families who have

children with Down syndrome.

Conclusion

These two families with children who have Down

syndrome experience different stressors that a family with

a typical developing child may not experience. The beginning

stressor of having a baby may be similar to other

families, but when the knowledge comes into the lives of

the parents that their child is going to be born with Down

syndrome, the stressor

grows, and the family perception of the situation may

change. Although perception may differ, the family’s resources

and the way they utilize the resources in response

to the stressor of having a child with Down syndrome

can demonstrate their resiliency. The ABC-X model of

family stress and coping is influential in realizing and

understanding the way the model connects to the individual

families, as well as the connection of how the model

can expand across different families based on the generic

stressors that are mentioned. The documentary film, “Ups

and Downs” explores the oral histories of two individual

families allowing the informational data to be shared in

137

a narrative way. The creative component behind a documentary

film helps grasp the attention of the viewer and

add authenticity to the results of the study by visually

seeing the participants and hearing what they are having

to say regarding their personal experiences.

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