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Reading Guide: Achievement by Proxy Distortion in Sports

This reading guide is intended to help you with the article below. Use it as a summary

and a map directing you to the article’s important points. You will be using this article to

help you complete Case Study 1 – Trophy Kids

Overall summary

Toffler and his colleagues are psychiatrists, doctors that diagnose and treat mental

illnesses. In their article, they present information on achievement by proxy distortion

(ABPD). APBD is an unhealthy parent-child relationship where the child is pushed too

hard to succeed. A parent with APBD lives vicariously through their children’s

achievements and may even become dependent on it. APBD can happen with children

with talents in any field, but parents with child athletes are particularly prone.

The authors’ goal is to present readers with the tools to recognize, diagnose, and treat

APBD. They also explain the stages and causes of the disorder. They also try to

distinguish APBD from healthy ways that parents want their children to succeed.

Even though this article is written from a psychological point of view, ABPD is

sociologically important because social contexts like family relationships, relationships

with the child’s entourage, and culture influence the condition.

Section-by-section article summary.

Read the following sections of the attached article. Skip any sections that aren’t listed

(they are also indicated in the reading).

Summary

Skip to the end of the article and read it first. The first sentence of paragraph two is the

most important: it has a definition of ABPD.

Introduction

The authors argue that sports medical professionals need to recognize ABPD. When

treating child athletes, professionals may encounter a parent with the condition. They

may also have to protect the child from the parent, and to refer the family for treatment

for this condition.

Table 1 presents some of the warning signs that a professional may encounter. The

“danger signals” indicate that a parent has become affected by ABPD, and may need

help restoring a healthy child-parent relationship.

An evolutionary historical perspective

In our biological and cultural past, adults were routinely cruel towards children, and their

wants and rights were ignored. Forced labour, slavery, abuse, and even murder of

children were all very common until very recently.

The point of this section is not to justify this kind of behaviour, but to argue that ABPD is

not that different from other ways that parents and other adults have mistreated

children.

The developmental tasks of relationship between high-achieving

children and their adult caregivers

This section examines how sports development happens when ABPD is present. The

authors argue that four elements contribute to the condition: the child athlete; family,

particularly the parents; the entourage, relationships with adults outside the family; and

larger systems, organizations such as corporations and colleges. Family, entourage,

and larger systems are all part of the social context that influences the child, and

influence the development of ABPD.

To get a sense of how ABPD can happen, see box 1. The authors use the example of

how a talented child golfer could be affected by ABPD, examining how each of the four

elements contribute to the problem.

Normal supportive range of achievement by proxy behaviour

While an extreme drive for achievement by proxy is unhealthy, it is normal and healthy

for parents and others to have some. For example, a healthy parent would be

encouraging of a child athlete, and would be happy when their child demonstrates talent

on the field and wins a sports championship. They are living vicariously through their

child, but in a way that is healthy for both the parent and their child.

An important concept in this section is normal sacrifice. To help a child succeed at

sports, parents must make sacrifices, such as time and money. Normal sacrifice is

reasonable and healthy, and does not create excessive pressure on the child, parent, or

family when it happens.

Maintenance of Support Achievement by Proxy Behaviour in Families

This section is about the ways that achievement by proxy turns from healthy to

unhealthy. The authors argue that ABPD behaviour often follows a series of stages:

1. Healthy patterns – these were described above.

2. Risky sacrifice – this is when parent-child sacrifices become unhealthy. For

example, a parent might charge thousands of dollars on their credit card for a

coach, and the child feels very pressured to do well knowing how much their

parent spent on them.

3. Objectification – at this stage, the child becomes almost a “thing” rather than a

person. The child’s “human” needs, such as health, protection, social interaction

with others, their desires, become unimportant.

4. Potential Abuse – there is no longer a distinction between the adults and the

child. This often means putting the child directly in danger, or creating the

potential for abusive situations to happen.

5. Distinct abuse – at this stage, adults begin behaviours that professionals or the

law would consider abuse. It can be physical (hitting, beating), emotional (insults,

yelling), or sexual.

The charts in this section are helpful. The five stages and some warning signals are

illustrated by figure 2.

Different types of parents show ABPD behaviour in different ways, as shown in table 2.

Parental Typologies in Achievement by Proxy Disorder

This section focuses on taking first steps to recognizing and dealing with ABPD. The

“red flags” are warning signs, and below this, the authors present tips that are helpful to

teach to parents and other adults to help prevent and reduce ABPD.

Role of the mental health consultant

How should a professional act when they encounter a child or parent with ABPD? This

section argues that professional must focus on children’s health. They must also avoid

supporting ABPD behaviour. For example, a doctor who clears a child with recurring

overuse injuries for competition may be contributing to ABPD. While it may seem

obvious that professionals should act in children’s best interests, professionals can have

incentives to ignore ABPD.

Another important role for professionals is to try to make changes in larger contexts that

support ABPD. For example, a doctor could work for a youth baseball league and fight

for changes that reduce how many pitches a pitcher can throw. Coaches and parents

could push talented young pitchers to throw too many, risking injury, so the doctor’s

actions would help protect the young athlete.

Achievement by Proxy Distortion in Sports: A Distorted Mentoring of High-Achieving Youth. Historical Perspectives and Clinical Intervention with Children, Adolescents, and their Families Ian R. Tof ler, MB, BSa,*, Penelope Krener Knapp, MDb, Michael T. Lardon, MDc aCharles R. Drew University of Medicine and Science/University of California, Los Angeles, 1731 East 120th Street, Los Angeles, CA 90059, USA bDepartment of Psychiatry, University of California, Davis, 2230 Stockton Boulevard, Sacramento, CA 95817, USA cDepartment of Psychiatry, University of California at San Diego School of Medicine, 3750 Convoy Street, #318, San Diego, CA 92111, USA

P ediatricians, psychologists, and child psychiatrists have long been awareof the dangers of child abuse. There has been a tendency to expect neglectand abuse among lower socioeconomic groups, although children, adoles- cents, and even adults in any demographic group are potentially at risk [1–4] (Table 1). In regarding children who have talent and promise, health professionals,

including sports medicine physicians, have had a blind spot to possible emo- tional neglect, physical abuse, and the potential harm of “by proxy” ambitions. In the last 2 decades, pressures on high-achieving children in sports and other

forms of artistic and academic endeavor have been recognized [1,5–16]. This special population is at significant potential risk for a broad range of neglect, boundary violation, and potential abuse in the push to achieve extraordinary success. Sports medicine physicians may be the first to recognize situations in which parents have gone beyond normal ambition for their child’s success. They may play a major role in protecting children from the reciprocal pressures of athletic organizations, which may influence and be influenced by coaches and parents to pressure children in ways that are pathogenic and even frankly abusive.

Clin Sports Med 24 (2005) 805–828

CLINICS IN SPORTS MEDICINE

* Corresponding author. E-mail address: [email protected] (I.R. Tofler).

0278-5919/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.csm.2005.06.007 sportsmed.theclinics.com

The extraordinary achievements by child stars attract breathless tabloid headlines and television specials. What actually, we wonder, are the requisite developmental hurdles in producing a 4-year-old golfing prodigy, a 6-year-old beauty queen, a 7-year-old pilot, a 12-year-old movie actor, a 14-year-old Olympic gold medalist gymnast, a 15-year-old champion ice hockey player, a 16-year-old Rachmaninoff virtuoso, or an 18-year-old National Basketball Asso- ciation (NBA) phenom? Voyeuristic publicity invites the inevitable questions: why can’t our own children be like the star?, and should any child be like this? Talented, driven children and their driven parents may excite and engender

open or grudging admiration, wonder, or envy. They may stimulate others to competitively emulate their child-rearing examples. They may also evoke some appropriate concerns and caveats about the methods used to foster and market these precocious talents. Were risks taken and corners cut in the development of those skills, actions that have jeopardized these children? Should the physician evaluate morbidity and mortality risks? Or is this infringement on a subgroup

Table 1 Stabilization/re-equilibration for ABPD families

Normal, healthy pattern Danger signals

Therapeutic indicators for positive change

Child development

Parents are sensitive to child’s stages, provide opportunities that are challenging but not impossible or unfair.

ABPD parents see child as an economic asset or as an impaired adult who needs to be forced to work harder.

Child’s interests are foremost. Parents can describe child’s reactions and empathize with child’s point of view.

Parent-child relationship

Mutually responsive, joyful, appreciative of each other’s strengths and challenges.

ABPD parents can be exploitative, domineering, critical, nonreciprocal, abusive, etc.

Parents can visualize and anticipate the effects of their own actions on the child and vice-versa.

Balance of child’s role within family system

Child’s needs are considered in relationship to those of siblings, both parents.

Other family members’ needs subordinated to the goal of training child and enrolling him in competitive situations.

Input of other siblings and both parents are taken into account. The parents can both articulate this input, and seek compromise.

Balance of family within community

Community experiences enhance positive parenting. Parents can support child’s efforts in school or sporting context.

Family is isolated, adversarial, migratory, financially struggling, and dependent on child’s potential career, performance.

Parents appreciate and encourage the contributions and involvement of spouse, other adults, and other children in the child’s life.

Model, ensure child sees and experiences mutually respectful interactions with other adults and children.

806 TOFLER, KNAPP, LARDON

of parents a paternalistic imposition of medical opinion upon their constitution- ally protected child-rearing practices [17–19]? Are parents who push their children to excel in sports any different from

those who push children to excel academically? The recent shooting of a coach by a disgruntled, frustrated parent or the beating death with a baseball bat of a Pony League player by a friend do seem to suggest otherwise [20,21]. This article describes a typology of high-achieving children and their

parents, and formulates a multidimensional response to these questions. First the authors present a brief historical view of childhood and of the development of psychiatric approaches to the problems encountered by talented children. Second, we hope to enhance understanding of the risks for talented children caused by adult distortions of perception and parenting, at the individual, family, systemic, and societal levels. These adult behavioral patterns may in fact be integral to the process of developing talented, successful children. The authors have chosen to use a psychiatric model, with the behaviors understood within a construct similar to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSMIV) [22] diagnosis of “factitious disorder by proxy.” Parental behavior ranges from normal to achievement by proxy distortion (ABPD), a distorted, potentially pathogenic behavioral zone, the extreme of which is frank, reportable abuse [13,15,16,23]. Third, the authors seek to broaden understanding of the dynamic, inter-

active process between children, both normal and gifted, with their equally talented, ambitious parents and mentors that enables them to achieve such degrees of success in sports at such an early age. Finally, we review possible responses, interventions, and management ap-

proaches that psychiatrists, sports medicine physicians, pediatricians, social workers and others interested in promoting the child’s welfare may use to address the ABP concerns of highly pressured, high-achieving children and adolescents. It should be emphasized that with all their nurturing and support, they remain, from a psychosocial, if not a biological perspective, a paradoxically underprotected group.

AN EVOLUTIONARY HISTORICAL PERSPECTIVE The fields of evolutionary psychology, genetics, and anthropology evaluate behavior within the context of at least 2 million years of hominid evolution. They represent complex human behavior as phenotypically similar to other traits [24–27]. A seemingly cruel pattern of exploitative behavior may actually conceal an evolutionary, adaptive form of “chromosomal empathy” for the future offspring [28]. Dawkins has moved beyond kin preference and reciprocal altruism in his book The Selfish Gene [24]. He coined the term “meme”( derived from the Latin root for imitation) to describe culturally beneficial, altruistic propagation of ideas, including those related to achievement for our children [24]. Our much more recently derived moral, religious, and ethical imperatives appear to stand in dramatic contradistinction with our cutthroat biological, psychological, and behavioral evolutionary past.

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Six thousand years of recorded human history confirms a somewhat dis- mal role for childhood. Children have been generally of inferior status, essen- tially property and raw material belonging to their parents or their parents’ masters. They were objects to be sacrificed and circumcised, goods to be bartered, slaves for work and sex, and fetishes to be venerated or discarded. This form of objectification was normative behavior from the lowest to the highest level [29–31]. Monotheistic moral and ethical tradition traces now- outlawed child sacrifice back some 4000 years, with Abraham’s divinely aborted sacrifice of Isaac [32]. The killing of infants, generally female, not necessarily as a form of sacrifice, but rather as a crude form of “fourth-trimester abortion,” continues routinely in China, India, and to a lesser degree all over the world, including the United States, where infanticide has actually increased over the past 30 years [33,34]. This also reflects an evolutionary gender differential preference, with the perceived advantages and greater economic importance attached to male offspring still being a prime factor. It was not until 1842 [31] that child labor was outlawed in British mines.

Building on pioneering 1924 League of Nations support for the international rights of the child, the United Nations developed edicts on child labor laws in 1973. These were revamped in 2002 by the International Labor Organization (ILO), but remain essentially unenforceable in most countries, with 210 million children worldwide working full time. Controversy over the last decade regard- ing American dependence on imports using exploitive child labor by Nike, Disney, and Kathy Lee Gifford has also highlighted this issue [35]. Overall then, despite dramatic increases in freedom, particularly in West-

ern countries, the child has remained an instrument for the implemen- tation of parental agendas, often for economic reasons, within an approving social context. In the United States, the fourteenth amendment due pro- cess clause essentially gives parents carte blanche as far as their child’s upbring- ing is concerned [17,36,37]. Inculcating the parental religious, educational, nationalistic, cultural, or sporting imperatives continues to be an inalien- able right. Children have long been regarded as offering a second chance to achieve

lifelong dreams and unfulfilled parental goals. An early Biblical example replete with ABP spectrum behavior is the story of the infertile Hannah praying in the temple to have a child. She bargains with God that if she is blessed with a male child, that his, the future prophet Samuel’s, entire life would be devoted to the higher cause of God, in effect repaying Hannah’s debt [38]. The Greek Olympics began according to tradition in 776 BCE in Greece as

an amalgam of religion, war, sacrifice, sex, death, and celebration [39,40]. The association of the athlete as a glorified and objectified warrior consolidated the Homeric agonistic ideal, still held today. that there is no second place on the battlefield. This “victory or death” motto (often “victory and death”) summed up Phidippides’ first marathon run and is still venerated today. When given a hypothetical challenge by G. Mirkin in a 1983 questionnaire, 80% of top US athletes would have taken a magic pill that would assure them

808 TOFLER, KNAPP, LARDON

of Olympic gold but cause their death within 1 year [41]. It should come as no surprise or coincidence that such powerful and seductive beliefs are often inculcated in our children. Is there anything wrong with this? Implementation of parental agendas

and goals opens the door for possible exploitation and abuse at many levels and degrees. That these abuses can occur in the name of love, support, or altruistic parenting, is at the very least ironic. When, one might ask, is a “good enough child,” to invert a Winnicott concept about parenting [42], simply not good enough for hard-driving parents?

PRIOR PSYCHOLOGICAL AND PSYCHIATRIC RESEARCH Since Freud, psychiatrists have been cognizant of the risks of projection of adult goals onto unborn and young children [43–45]. At the time of our birth we may be invested with all the pluripotential properties of a bone-marrow stem cell, but our limitations, defects, and total dependence, as well as our potentials, are never more obvious than at that moment [46]. Motivation theory delineated “the need to achieve”—the normal range of

behaviors that propel humans and their offspring to succeed at the highest levels. Beginning with Hull’s drive theory based on habits strengthened by positive reinforcement, there are multiple approaches. Murray developed a classification in 1938 that was further refined by Atkinson, in which among 20 basic human needs he described the needs to accomplish something difficult; to master, manipulate or organize physical objects, human beings or ideas; to achieve this as rapidly and independently as possible; to overcome obstacles and to attain and aspire to a high standard; to excel one’s self; to rival and surpass others; and to increase self regard by the successful exercise of talent. Reiss and Havercamp [47] developed a useful standardized measure of 15 core motiva- tional traits that have been used to explore athleticism and sports motivation. They found athleticism to be significantly associated with motivational traits for social contact, family life, physical exercise, competition/vengeance, and power/ achievement, as well as with low curiosity levels [36,47]. Further developing the ideas inherent in Lewin’s resultant valence theory,

Thibault and Kelly presented a differential satisfaction/dissatisfaction compari- son level between parents and their children. They evaluated changes in the “need to achieve” to be ambitious or aspire to success, defining a “neutral point,” which may vary over time during development. McLelland developed this idea in discussion of early independence training and growth of achievement motiva- tion. A gender bias, described by Horner, toward male achievement has tradi- tionally been associated with a mirror image—a concurrent female need to underachieve, not to achieve, or to fear success that has changed significantly in some but not all societies over the past century. Cloninger discusses differ- ential responses to harm avoidance, reward dependence, and novelty seeking, among other genetically influenced traits that can affect drive for success and are associated with involvement in risk-taking extreme sports such as rock climbing

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that require high novelty-seeking and low harm-avoidance. Motivational approaches to achievement may differ among groups of people, different cul- tures, and indeed entire countries. These differences, not surprisingly, affect responses and results in areas as disparate as geopolitics, economics, financial success, education, and of course national and international sports achievement and success [48]. Murray Bowen [49], psychiatrist and family therapist coined the term “family

projection” to describe the spoken and unspoken goals and roles assigned by families, that affect an individuals’ ability to “differentiate” as an adult. The Swiss psychologist Alice Miller, drawing from sources such as self

psychologist Heinz Kohut, pediatrician/analyst D.W. Winnicott, and analyst Margaret Mahler, further developed understanding of this important dilemma in child rearing, which she described as “the drama of the gifted child” [50]. According to Miller, the most appropriate objects for narcissistic gratifica- tion are a parent’s own children. She stated that “from the very first day onward, he [the newborn baby] will muster all his resources to this end, like a small plant that turns towards the sun to survive” [50]. The intuitive un- derstanding, reciprocity, and attachment a child has for his parents and what he can do to please them is central to these ideas. She states that “in spite of excellent performance, the [specially gifted] child’s own true self cannot develop” [50]. This conditional love that objectified, highly successful children, the products

of “poisonous pedagogy,” can experience often comes at a high price—the very authenticity of that individual. Miller’s many books since have used famous case examples to further de-

velop her ideas, particularly those about early abuse, pathogenic parenting, and its effects on the developed high-achieving adult [50]. Meadow [51] included “Victa Ludorum by proxy” in more recent discus-

sions on variations of Munchausen’s syndrome by proxy in the pediatric literature. This reference to the academic prize of excellence rewarded at British schools reflected his concern that ambitious parents could potentially dam- age their children by overstressing or pushing them toward apparently laud- able goals.

THE DEVELOPMENTAL TASKS OF RELATIONSHIP BETWEEN HIGH-ACHIEVING CHILDREN AND THEIR ADULT CAREGIVERS Children do not develop in a vacuum, whether they are normal or talented and gifted. Their development is a highly interactive process between child, adult, and adult systems. Trainable, genetically able, talented, and resilient children have sufficient “right stuff” of suitable temperament, the right body habitus, psychological malleability, and obedience to excel. In the twenty-first century gender remains a major cultural variable in international parental attitudes, reflecting a bias toward a perceived need for higher male achievement. Marsh and colleagues [52–54] have elucidated the “big fish, little pond” and

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BOX 1: HIGH POTENTIAL FOR ACHIEVEMENT BY PROXY DISTORTION: SYSTEMS INVOLVEMENT FOR ASPIRING PROFESSIONAL CHILD GOLFERS

Child

1. The child has a clear ability for golf, nurtured from a very early age by ambitious parents.

2. Golf aptitude is developed by strenuous daily practicing for 2–10 hours per day (up to 70 hours per week!).

3. Psychological “toughening up” for resiliency under pressure 4. Social isolation and sacrifice, delayed gratification for normal psycho-

social development—a large part of the early training for junior profes- sional golfers

5. Unidimensional identity if isolated from school and peers. Home schooling can be potentially problematic.

6. Stressful relationships with parents and less talented siblings in which the child’s performance and level of success are clear factors in a realistic sense of “contingent” love

7. “Contingent Love” is a good model for later opportunistic “fair weather” relationships when on adult tour. “I don’t know who to trust” is a nor- mal reaction to involvement with professional friends, family, sponsors, and agents.

8. The young professional golfer can begin to objectify and distance from himself as well. Like his parents, entourage, and the larger systems, he may begin to view and accept himself as a commodity or product.

Family

1. Reciprocal positive, noncontingent support from parents and siblings for emotional and attachment needs is ideal.

2. Financial support for the child’s career may be upwards of $100,000 per year.

3. Parents may depend on their child’s financial contract for their own lav- ish lifestyle and support. Role reversal and diffuse boundary situations can be dangerous.

4. Parents can take on roles of both the child’s entourage and larger systems to save money or provide a shortcut to success. Father may continue to be primary golfing coach, personal trainer, and tutor combined.

5. A business relationship with the child rather than a parent–child relation- ship is possible and often problematic; it may lead to later “divorce.”

6. Parents may want to keep confidential information about the child from their agent, a “part owner” with the parents of the child. For exam- ple, psychological or physical injuries such as overuse injuries (eg, stress fractures) can be deliberately ignored. Parents may medicate the child without medical supervision for performance enhancement and other purposes.

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Entourage

1. Personal trainer/coach: spends most of the time with the child; a highly influential paid “friend.”

2. Agent: a very powerful influence, often in surrogate parent position, with sometimes an even greater influence than parents, because parents have in effect “outsourced” the child’s ownership to the agency.

3. Tutors/academic trainers: important but peripheral. No teaching qualifica- tions are necessary, and academics are not considered important to the child’s development.

4. Travel agent: very important when traveling on a “shoestring” in early career.

5. Social relationships: fellow golfers primarily; initially peers, friends and competitors. When the child joins the tour, friends and adult competitors are now business rivals, with varying degrees of social isolation possible for the young golfer.

6. Performance enhancing “guru,” sports “psychologist”: unlikely to pro- tect the child’s confidentiality; tend to use name recognition for advertis- ing purposes.

Larger Systems

1. Golfing schools: for example, a Florida golf academy where “good isn’t good enough” is the motto. Minimum age for enrollment is 8.

2. US Children’s Golf Association; American Junior Golf 3. Swing and stroke coaches/teachers 4. Agencies: owners of schools, therefore running professional player

development “nurseries,” controlling the flow and shaping the edu- cation and values of juniors funneling into the tour. They run their own tournaments.

5. Tour/qualification school: no age limit at this stage. 6. College/National Collegiate Athletic Association (NCAA) golf circuit:

involves scholarships from high school level. Also involves “delayed gratification” in terms of temporarily delayed access to large contracts from the professional tour. Allows for more normal adolescent social development and access to higher education and degrees, with potential careers outside of or after golf, peer relationships—buffers against the unidimensional identity quality of the professional child.

7. Multinational companies and other sponsors: golf equipment (eg, Callo- way, Rossignol, Telem, Nike); have their own career-long demands.

8. Advertising agencies: in conjunction with agents. Goal is to “build a brand product,” whether through lifestyle or sexuality, particularly for teenage females, but also “cool” males. Tend to create a “false self,” about which the young golfers are often ambivalent.

9. Media: special deals with TV companies through an agency may promote the young player by pairing with contracted “stars” from the same agency, for example. Importance of “marketable personality”

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“reflected glory” effects. Their research addresses the sense of relative achieve- ment, self concept in different cultural environments, through different frames of reference. Children and their families often realize that their abilities are not quite as great as they initially believed; for example, when a child moves to a school for gifted children and realizes he is now only average or even below average in a more challenging context. To excel, optimal interaction with experienced, ambitious, inspirational,

and charismatic adults keenly adept at interfacing with the systems is critical. That interaction may focus training and develop the child’s skills to a sufficiently high level to achieve success. The child and his adult mentors combine their talents in a relationship that, given opportunity, luck, and other intangibles, culminates when that potential is brought to fruition, rendering the talent a career-worthy, marketable commodity. The relationships that occur in the sport of junior golf, detailed in Box 1, provide an excellent illustration of how multiple individuals and systems may interact in the process of producing a champion (Fig. 1) [14–16,55,56].

and advertising brand clear here as well. Enhance objectification of the youngster.

10. Medical systems: internist, orthopedist, psychologist, psychiatrist, hospi- tals and health maintenance organizations (HMOs). Rarely work in concert to enhance the child’s overall physical and psychological development, and may have their own agendas to promote.

Fig. 1. Systems involvement for aspiring child golfers and other “professional” children.

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ACHIEVEMENT BY PROXY DISTORTION AND FACTITIOUS DISORDER BY PROXY There is an evolutionary adaptive element with widespread social and cultural acceptance and sanction for highly focused and sometimes distorted, even abusive, parenting behaviors described in this article. By selecting the term APBD [13–15], the authors have placed them within the range of behaviors known as the psychopathology of everyday life. Factitious and factitious by proxy disorders [22] from the psychiatric nosology of DSMIV, and Diagnostic and Statistical Manual IV Text Revision (DSMIVTR) have also been employed as models for describing these behaviors. In 1977, English pediatrician Roy Meadow [10] noted that highly engageable,

intelligent, and apparently caring mothers could induce illness and even death in their children while themselves seeking to be nurtured in the sick role by proxy. This nurturance was often of a systemic nature, the result of the care and support of doctors, nurses, social workers, support staff, and even the institution itself, which provided a form of support and identification [18]. Meadow placed this behavior within “the hinterland of child abuse” [10], which he called “Munch- ausen’s syndrome by proxy,” named factitious by proxy (FBP) disorder in psychiatry nomenclature [22]. Meadow [51] and Schreier [57] affirmed that “it was expected that profes-

sionals other than doctors would be involved.” Jones [58] opposed this diag- nostic broadening, suggesting that to include a wider umbrella of diagnoses and interactions beyond DSMIV criteria that “external incentives for a behavior such as economic gain are absent” would dilute any meaning from the diagnosis [22,58]. It remains difficult to ever be sure of the internal motivation of a person.

Attention-seeking behaviors or financial gain at the expense of the child’s normal developmental needs may be just as potentially pathogenic. Externally moti- vated behaviors, those of a by-proxy sense of achievement and other collateral benefits such as fame, are also present in accepted cases of FBP [22,38,57]. These incentives may not be the primary motivation, but they may still be vital and significant factors in the pathogenesis and perpetuation of FBP cases. This model explains interfamily social processes and motivations leading

adults to place their children in potentially risky, even dangerous and abusive, situations. Parents, teams, sports, and even Olympic committees may use children to pursue “a higher goal” such as national or Olympic-level sports promotion, entertainment, or the arts. Consideration for short- and long-term potential consequences to the child may be lacking. For example, the Australian government paid 32 million dollars per gold medal in the recent Athens Olympics, a price well worth it to the population of that country, judging by the lack of negative reaction [59]. Just as parents’ response to their child’s physical illness may range from

normally supportive and help-seeking, through anxious doctor shopping, to the creation of factitious illness, so may parents’ encouragement of their chil- dren’s achievements range from normal support to overzealous pressure. The

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authors describe this continuum below, delineating the normal supportive range, defining the disorder, and clarifying the four levels of ABPD.

NORMAL SUPPORTIVE RANGE OF ACHIEVEMENT BY PROXY BEHAVIOR Normal supportive range of achievement by proxy behavior refers to adult pride and satisfaction experienced in supporting a child’s development while also nurturing that child’s abilities, special talents, and performances. Although the parents and family may benefit financially and socially from

their child’s success, these are not the primary goals; rather, they are collateral benefits of more general altruistic behavior. The individuality of the child or adolescent is acknowledged, and the involved adults have the ability to distin- guish the child’s needs and goals from their own. Normal adult pride in a child’s performance includes parents sharing the triumph of a child scoring a goal in a youth soccer game despite the team’s loss, with which they are able to empathize on both an individual and team level. Sometimes a parent may insist that a child decrease or even quit an activity cherished by both, if the overall impact is deleterious to that child’s developmental progress. Good parents should be able to monitor their own reactions, and to differentiate their own from their child’s goals. A child must never feel that the love of her parents is contingent on success in one field or endeavor, be it an educational, sporting, career, or social goal. A community’s pride in their children’s success is illustrated in the 1991 book

Friday Night Lights [60], later a film, which vividly portrays reactions of highly ambitious families in the small Texan town of Odessa. Adult behaviors both in the normal range and in severely distorted and pathogenic ranges of ABPD are also depicted inHoop Dreams [61], the book and later the superb documentary by the director of Friday Night Lights that follows two teenage basketball players in the inner-city Chicago Cabrini Green housing project as they pursue their National Basketball Association (NBA) dream. The normal range of parent support for children’s success also includes an

element of “normal sacrifice.” Parents want to and are expected to make reason- able sacrifices in their attempts to provide opportunities for their children. Children, in turn, are expected to behave in a responsible fashion, striving for success at the highest manageable level that they are capable of. This does not imply giving carte blanche to adults to place inappropriate and unacceptable pressures endangering their youngsters’ physical or mental health to achieve success in any area.

MAINTENANCE OF SUPPORTIVE ACHIEVEMENT BY PROXY BEHAVIOR IN FAMILIES: ACHIEVEMENT BY PROXY DISTORTION—DEFINITION AND SPECTRUM DESCRIPTION ABPD can be defined as occurring when a child is placed, with his collusion, volitional or otherwise, in a potentially exploitative situation in order for a

815ACHIEVEMENT BY PROXY DISTORTION

perpetrating adult or adult system to gratify conscious and unconscious adult needs and ambitions for the attainment of certain goals or achievements. ABPD could be considered as pathogenic and potentially problematic parent-

ing. Much of this behavior lies in a “gray zone”; however, at its most severe, when unacceptable physical or psychological harm is inflicted, it can be a variant of child abuse [1,13–15]. Children are intentionally placed in situations in which they must focus on a single activity to the exclusion of all others. In such cases, most or all other childhood activities may be subordinated to goals such as attaining sporting, entertainment, music, or educational success. The goal may be pursued to the detriment of the child’s physical and psychological well-being, and may put overall developmental progress at risk. The adult’s vicarious experience of the child’s success may gratify a desire

to derive collateral benefits from that success. These benefits may be manifold and may parallel the child’s clear benefits. They include fame, financial gain, career advancement, peer recognition and respect, stronger relationships with the child, social acceptance, and improved socioeconomic status. The vicarious success may benefit an individual adult, a system, a company, or a local or national entity. Just as in FBP, a role reversal occurs in which the child nurtures the adult. Thus the adult’s vicarious achievement of success hints at an under- lying dynamic motivation for ABP: the adult gets the child to provide emotional and sometimes economic nurturance [37]. The authors describe five stages of ABP. The first stage falls within the normal

range of ABP behavior. The next four stages progress through potentially pathogenic range of ABP distortion. There may of course be significant overlap between normal ABP behavior and all ABP distortion components. The general trend, however, is from benign to abusive.

Risky Sacrifice Risky sacrifice is a mild loss of an adult’s ability to differentiate his own needs for success and achievement from a child’s developmental needs and goals. At this level of behavior, a family or a system may construct conditions for

a child or adolescent whereby there is increasing pressure, of a subtle but easily comprehended nature, that the child must “perform.” Parents may take a second or even a third job to support a child’s career. Families may move closer to a gym or training facility, or may allow a 13-year-old to make the decision to travel to a different state to live at a training facility, or even to be adopted into the custody of a coach. Plausibly deniable rationalizations that may be emotionally compel- ling become major conscious and unconscious defensive strategies at this stage. Parents may appear helpless and even passive with comments such as “I want my child to train less, but she loves it. If she insists on training 8 hours a day, 6 days a week, how can I say no? I love my child.” Children and adolescents collude with their parents and coaches goals, as shown by comments of encour- aged pseudoautonomy such as, “It is my decision to play injured; no one forces me to.” When the child gets injured, neither the parent nor the coach need feel responsible. An adult’s and particularly a parent’s role to protect the safety of the

816 TOFLER, KNAPP, LARDON

child may be abrogated. The level of sacrifice demanded from a child surpasses defensible, safe levels. Re-establishing normal parental autonomy—as for example when parents

insist that a child miss practice to complete a school assignment—may produce unpleasant situations in which a respected, charismatic coach threatens to remove the child from his roster, saying “there are others who are more serious and may be more worthy.” The sacrifice is now not only expected, it is demanded. To resist this external and internal pressure requires not only insight but also painful parental courage.

Objectification Objectification is the moderate loss of the ability of adults to differentiate their own needs and goals for success and achievement from those of the child. At this stage, the child begins to become an object rather than a person.

The intensity of the pressure on a child is further increased. With increas- ing social isolation, a child or adolescent becomes increasingly defined by one activity in which she is able to perform well, and begins to develop a “unidimensional identity” [15]. Excessive focus on the sport or other achieve- ment necessarily isolates the child from social interactions, and potentially hinders her developmental possibilities, limiting many social, physical, and emotional experiences. Objectification of the child is associated with the adult caretakers’ loss of the ability to distinguish their own needs and goals from those of the child [62]. This leads to rationalizing routine risk-taking, which also occurs in states

of abusive neglect, such as when a mother severely burns her child to teach him that he should not play with matches. A child may be encouraged or even forced to train at levels that are potentially health-endangering. A young athlete may be advised to use pathogenic forms of weight control that may lead to life- endangering eating disorders. Parents, coaches, and sometimes entire systems, such as the media and governments, turn a blind eye to pathogenic behaviors or actively and passively encourage and support them. To involved adults, the end justifies the means. Winning is the end, and

the objectified child becomes the means. It is much more difficult to empathize with an adolescent’s pain or experience once the youngster has become objecti- fied. Emerging malleable, talented young entertainers, actors, musicians, and sports stars understand what is expected of them and may actively accept it. They may cope by emotionally distancing themselves from their own feelings, colluding in this objectification of themselves, a process resembling Anna Freud’s concept of “identification with the aggressor” [63]. The 14-year-old gymnast who assumes full responsibility for training with a broken wrist, with the full knowledge of coach and parents, is a good example. The child prodigy’s body and mind become, even to herself, machines to be driven and exploited in the pursuit of a “worthy” goal. “She can leave at any time” is a frequently heard statement from parents and coaches, echoing the claim of cult leaders, but not as obviously exploitative.

817ACHIEVEMENT BY PROXY DISTORTION

A recent Sports Illustrated article [64], quoting an agent closely involved with a family, exemplifies the rationalizing employed to justify this adult behavior: “I know how this looks. I know you are going to say that what is going on here is weird. People are going to say it looks bad, like I’m manipulating this kid. Like I’m trying to take advantage. But I’m not going to get a thing out of this. My only hope is that maybe, one day, when D is in the NBA, he can come back and sponsor my team. We’ll call it the Demetrius Walker All-Stars. If he wants to do that, great. If not, that’s fine. I’m doing everything that’s right for the kid, and right now, what he wants, what I want, what his mom wants—we all want the same thing, and that’s for D to succeed and grow and graduate and do all those things he is supposed to do.”

Potential Abuse Potential abuse is a severe or complete loss of the ability of adults to differentiate their own needs and goals for success and achievement from those of the involved child. At this level, the child is at risk of becoming chiefly an objectified and exploited

instrument of the involved adult’s goals. These goals are pursued without regard for short- and long-term potential physical and emotional morbidity or mortality in the child. Adults, whether they be parents, mentors, coaches, or sponsors, may

often appear to be perfectly attuned with the child—“She is my best friend”— but all the features of risky sacrifice and objectification may still be present. A child may become, in essence, an adult’s meal ticket. If badly injured in practice, it is because “She is a daredevil” (conditioned from age 4 to ignore pain and to take risks). If injured representing her country, team doctors may have colluded with her competing with potentially catastrophic injuries. Here, the national team system is an important component of a potentially abusive process. The media and its spectators and consumers, ourselves, are also part of this cascade. If an adolescent boy is sexually abused by a guardian or coach, such as occurred recently in the Canadian junior hockey league, he may remain silent, fearing he will not be believed. If he reports the abuser, in all likelihood his future career will be terminated, his character besmirched as an ungrateful liar, and his emerging sexual identity questioned by others, and perhaps by himself as well.

Distinct Abuse The loss of ability to differentiate one’s own adult needs from those of the child has led to damaging behaviors toward to the child that can be life- threatening or can cause severe lifelong emotional and physical scars for the child.

Physical abuse Performance-related results lead adults and sometimes other children to assault a child, or to encourage the child to take severe physical risks on a repeated

818 TOFLER, KNAPP, LARDON

Ta b le

2 Pa

re nt al

ty po

lo gi es

in A BP

D

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ty pe

St re ng

th s

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po sit iv e/

ne ga

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bu lli es

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en t.

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de ve lo ps

a m ar ke ta bl e sk ill /l on

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rv ic e to

pa re nt al

go al

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is us ed

an d m ay

be ab

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; m ay

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cu ltu re

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fe el s dr iv en

to su cc ee

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pl ea

se pa

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bu tl os es

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se lf

if fa ils .

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ca n em

br ac

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tte rn ,a

vo id

it, or

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fa ilu re .

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te d

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ca n

do be

tte r du

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fro m

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rie nc e/

m ist ak

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rc ha

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ea rly

lif e am

bi tio

n

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try to

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te w ith

ch ild

. C hi ld

ex pe

rie nc es

pa re nt ’s

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s of

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jo in

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go al s.

819ACHIEVEMENT BY PROXY DISTORTION

basis to improve performance. This can also be demonstrated by tacit encour- agement to use potentially risky performance-enhancement drugs.

Emotional abuse Denigration, belittlement, and verbal abuse in the service of “toughening up” the child and motivating him may lead to the child’s improved performance, but also to his increased dependence, his isolation from peers, his missing devel- opmentally important experiences, and to his emotional constriction.

Sexual abuse Sexual feelings may arise in the protracted and intense closeness of a training relationship. It is the mentor/coach’s responsibility to contain and manage these feelings. If a mentor takes advantage of the power differential between himself and a young student, this constitutes sexual exploitation and is reportable. This power differential and the vulnerability of a child is most palpable when on the verge of success [1]. Inappropriate sexual relationships may occur over time, and may reflect a form of favoritism, and if terminated when a younger, more talented or more beautiful replacement is found, may lead to a subsequent loss of status for the victim. Parents may be aware of physical, emotional, or sexual abuse by coaches

or other mentors but allow it to continue because of the potential rewards of success. Parents, coaches, mentors, teachers, and systems are all at risk of perpetrating

distinct abuse. Although it remains difficult to prove and prosecute this abuse, it is beyond

dispute that this behavior occurs and is not uncommon (Table 2) (Fig. 2).

Fig. 2. The ABP distortion spectrum.

820 TOFLER, KNAPP, LARDON

PARENTAL TYPOLOGIES IN ACHIEVEMENT BY PROXY DISORDER Response to Achievement by Proxy Disorder: Management, Recommendations, and Interventions A critical first step in the management of ABPD situations is to recognize the potential risks to professional children and adolescents in sports. Psycho-education of parents, mentors, and coaches will refocus attention on

the child’s developmental needs, the importance of supportive adult relation- ships, and the motives of adults and children in a particular situation. Adults must be encouraged to frequently and honestly re-evaluate their own and other interested adults’ goals, motives, and agendas in the professional development of a child.

Recognize the “Red Flags” of Achievement by Proxy Disorder Examples illustrating when adults are being overdirective and too goal-oriented with children include:

1. Parents making life decisions based on a child’s activity; for example, selling their home and moving to another city, getting a second or third job so that their child can work full time as a gymnast, or removing the child from regular school.

2. Parents may allow the coach to make all decisions in their child’s life. They may even suggest that the coach take custody of the child, so that the child can “live and breathe the sport.”

3. The parents, the 13-year-old competitor, the coach, the orthopedic surgeon, and the team manager are all aware of an injury, but all agree that the decision to compete with a broken wrist is the child’s to make.

4. The child develops psychosomatic illnesses from malingering: factitious, hypo- chondriac, conversion, and pain disorders that can help to consciously or unconsciously escape from or avoid training or competition. Psychiatric ill- nesses such as depression, anxiety, and substance abuse may also be unmasked by the stresses of competition.

Providing self-help tips to parents, educators, and coaches assists them to fulfill their obligations to children. It is necessary to recognize and respect the child’s individuality and age-appropriate differentiation from the involved adult. This can be accomplished without denying outstanding children and adolescents the opportunity to succeed at any level. Some examples include:

1. Balancing career goals with developmental goals and requirements. If an adolescent takes a summer vacation with friends and family, and misses coaching or classes, this may go against both the child’s wishes and the acting coach’s orders. Being able to be a parent and to sometimes resist pressures from the child as well as internal ambitions and external professional pressures is an important skill. The ability to say “no” is a vital if disagreeable part of being a parent.

2. Parents must be able to objectively examine their own motivations for encour- aging or pushing a child to develop a skill or talent. Help the parent to ask, “Am I doing this for my child or myself? If I am doing this a little for myself, where does my child fit into this equation?”

821ACHIEVEMENT BY PROXY DISTORTION

3. The parent or involved primary care physician must know when to consult with or refer to a psychiatrist or other therapist or counselor. Parents often need an outside specialist to help them better comprehend the “big picture.” A more objective view of the child and other family members, including siblings, when the risks and benefits of a child’s involvement in an activity are great can be very helpful. For example, when parents feels themselves trusting a charismatic coach over their own instincts, getting a second opinion is crucial.

4. Parents and physicians must learn to recognize risky rationalizations such as “plausible deniability.”

ROLE OF THE MENTAL HEALTH CONSULTANT Using a flexible, developmental biological/psycho-social/systemic and cul- tural model, therapists may guide involved adults to support the progress of a child. Such a model allows for gauging developmental progress against an ethical or moral risk/benefit analysis of the child’s involvement in professional activities such as acting or in sports training. It provides a context of the child’s overall development from which to view possible developmental risks of over- specialization and social isolation from peers, as well as other physical and psychological morbidity. It assists in judging whether that child’s continued involvement is justified by the trauma or illness induced in the service of a professional goal. The mental health professional, whether a therapist for the child or family

or a consultant to the coach or sports physician, must rapidly establish bound- aries clarifying his primary role. The therapist must recognize and avoid the interference of personal ulterior motives or obligations that may inter- fere with protecting the child from abuse or unnecessary risk taking. If the client is a famous child or family, this be even more difficult. Only if the therapist can recognize such issues will he be able to avoid collusion with exploitive patterns. It is important to confront or detoxify rationalizations emanating from parents, governing bodies, or the children themselves that endanger children. All parts of the system need to be aware that, as in the case of a suicidal

adolescent, confidentiality is inappropriate when the child is at significant risk. Any abuse must be reported to appropriate authorities. The risks of systemic collusion by omission or of not communicating important information are greatest when the stakes are high. An example is if a national gymnastics organization encourages, hides, or

turns a blind eye to chronic injuries, eating disorders, analgesic abuse, or sexual or physical abuse of minors in the run-up to the Olympic Games. National pride and patriotism are invoked to justify any expediency. For a minor, to represent one’s country seems to confer honorary adult status. But the minor is still a minor, and coaches and team physicians are responsible for protecting children from situations such as competing with a severe injury. Because of the potential for exploitation and abuse, a rigorous history must

be taken from the child and others involved in the situation. As in all mental

822 TOFLER, KNAPP, LARDON

health evaluations, history must be accompanied by a thorough mental status examination, and by indicated investigations such as physical and psychological testing, blood work, cardiac work-ups, and other physical, physiological, and radiological investigations. Toxic screens for substances abuse and use of performance enhancement drugs may be necessary. Forensic assessments may sometimes be required. Mandated reporting is required in situations when abuse is suspected. ABPD standardized interviews and risk/benefit scales can con- tribute to our understanding of these conditions. The role of psychiatrist as physician advocating for the safety of children at

all levels of endeavor in society includes advocating for high-achieving children and adolescents in sports. Because of the potential risks for exploitation, there is a growing need

for legal protection of the rights of professional children, and development of enforceable laws to limit hours of training. Removal of loopholes that sug- gest that these working professionals are “simply enjoying themselves and having fun” will be useful. Changes in the rules of Olympic competitions to eliminate dangerous routines and to minimize the unrealistic and health- risk–taking aesthetic demands of judging, and age limitations favoring, or at the very least not sabotaging, adult participation are examples of useful child psychiatric interventions at the general societal level, and have been presented elsewhere.

VIGNETTE WITH SUGGESTED CLINICAL STRATEGIES G.D., a 14-year-old Asian American female, is badly injured in a vaulting routine, sustaining spinal cord injuries at the C6–7 level. Father A.D., a 40-year-old professional soldier, has been instrumental in her involvement in gymnastics despite having no training himself, and was her first coach. It was his ambition initially that she become an Olympic gymnast. Mother, M.D., a 39-year-old executive, is only minimally involved in her

daughter’s gymnastics. She seems to be somewhat absent during G.D.’s recov- ery. D.C., a 35-year-old coach, has been working with G.D. almost daily since age 8, and was her major role model, confidante, and “big sister,” a mother figure traveling with her to all competitions. D.C. believed that G.D. would reach the elite level, and possibly the Olympic level. She attends all therapy sessions during the hospitalization, giving advice to staff members.

Some Quotes

14-year-old: “ I don’t feel sorry for me, and I don’t expect others to be either, I don’t feel sorry for them [coach and family].”

Father: “Of course I was in shock at the beginning, but you’ve got to adapt … . I guess I was ready for something like this, having my mother in a wheelchair most of her life … you’ve got to adapt and adapt quickly. I am certain my daughter will improve and I won’t be surprised if she returns to gymnastics at a competitive level. If not, she will be a success at whatever she puts her mind to.”

823ACHIEVEMENT BY PROXY DISTORTION

Coach: “As soon as it happened I felt, and I know this sounds selfish, that this was the end of my chance to coach a champion. I was upset about the loss of her and my own future. It doesn’t matter any more … all I care about now is will she be able to walk again, will she have a functional life? Everyone wants me back coaching, but I’m not ready yet. None of the other children have quit … .”

Possible Therapeutic Strategies Illustrated by the Vignette

1. The importance of anticipatory case finding methods. In this case a psychia- trist had not been consulted beyond initial trauma issues, but was able to be of benefit in immediate and longer-term management. Establishing credibility within school systems and sports medicine facilities and with parents and teams can only occur over time.

2. Be flexible in providing therapy, including face-to-face, family involvement, and intermittent long distance telephone involvement.

3. Build on the child’s and the family’s strengths. Recognize adaptive “positive denial” strategies, as well as maladaptive coping strategies.

4. Do not prematurely interpret child or parental behaviors. This may result in the family fleeing therapy. In this vignette, the father’s striving and goal directed- ness may actually facilitate this child’s resilience during her long, slow, painful recovery toward a fuller physical life; however, his emotional distance and the pressure he places on her may limit her tolerance and ability to express her own affect. This may lead to masked and unrecognized psychopathology in both the short and long term, with potentially severe consequences, including major depression and suicide.

5. The importance of establishing rapport and alliances with all members of the extended family. This may include custodial and noncustodial parents, and a coach and even the coach’s family in surrogate parental or family roles, after full permission has been obtained. If the child’s biological parents refuse or are reluctant to engage in therapy themselves, the surrogate parent/coach may be the best person to work with for ongoing contact with the child or adolescent and the parents. It is crucial to include the adults who are closest to the child.

6. The child’s injury is traumatic. Trauma should be anticipated and dealt with when it occurs. A parent or coach’s reaction to the trauma of witnessing and supervising an athlete during a life-threatening and altering event can- not be minimized. Short- or long-term trauma-related psychotherapy may be helpful. The adult may be able to model her own fairly adaptive coping skills for this child recovering from and dealing with ongoing lifelong physi- cal impairment.

7. Broadening the alliance with the child, parents, and coach. Being able to empathically approach the reasons a parent may be covertly or overtly creating extra and possibly unacceptable ABPD pressure on a child. In the vignette, both the father and the coach appear to be straddling the risky sacrifice and objectification levels of ABPD, with mother apparently less attached to the child in all respects.

8. Understanding the child, parents, and the coach’s needs and goals is critical. To do this, the therapist must be able to deal with her own possibly negative judgments about the situation. Attempt to take each person’s perspectives into

824 TOFLER, KNAPP, LARDON

account. This may help the clients accept the existence of problems and to consider the benefits of psychotherapeutic intervention. Unfortunately, many individuals disparage the “weakness” of any involvement with psychosocial supports. If parents are covertly creating ABPD pressure, trying to empathize as much as possible with them helps them toward alternatives and different strategies to fulfill their own needs for the vicarious pride, success, and achievement currently funneled through their child.

SUMMARY When there is the possibility of reaping financial reward or other collateral advantage, children have historically been exposed to the risks of exploitation and abuse. There may be an evolutionary behavioral basis to the need to have children succeed and achieve, but “enlightened times” have not altered this social phenomenon. Primary prevention of this exploitation through outlawing the most flagrant abuses; secondary preventive strategies through minimizing risks; anticipatory guidance; and tertiary preventions including psycho-education will minimize the pathogenic dangers of ABPD. The authors define ABPD as a condition that occurs when children are

placed, with or without their collusion, in a potentially exploitive situation in order for a perpetrating adult or adult system to gratify their own needs and ambitions for the attainment of certain goals or achievements. We have provided definitions, descriptions and examples of four stages of ABPD be- havior: (1) pathogenic risk/sacrifice, (2) pathogenic objectification, (3) potential abuse, and (4) distinct abuse. This typology will increase awareness of this phenomenon, especially in the practice of sports medicine. It should facilitate communication, enabling sports psychiatrists and other sports medicine profes- sionals to identify the “red flags” that can lead to exploitation and potentially to abuse of children and adolescents in sports. It can further contribute toward psycho-education of ABP self-help skills, especially in the understanding of parental and other adult motivations; it can help young athletes in understand- ing their colluding roles for their behavior and risky rationalizations; and it can enhance prevention strategies.

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