Dear Ann Landers,
urrah for the gal who signed herself "Honest." I'll bet the true number of bedroom Sarah Bernhardts in this world would be a shock-even to you. Yes, I am one of the vast army of actresses. Why do we do it? Because we love our men and don't want them to feel inadequate. We accept the fact that we have been biologically short-changed by Mother Nature and that it isn't any-body's fault No woman ever enjoys sex as much as a man does, and she never will. So we just go on doing our little act. Knowing that our men are satisfied is enough for us. Do you have the guts to print this? ENJOYING NOTHING BUT THE APPLAUSE IN KANSAS CITY

DEAR K.C.,
If the applause is all you're enjoying, you are gypping your-self plenty. Your basic theory is incor-rect, and I hope you will have the guts to discuss/-your problem with a thera-pist so you can begin to experience what is rightfully yours. The female orgasm has possibly been the subject of more debate and litera-ture than any other area of human sexuality. But fortunately, since the work of Masters and Johnson in the 1960s, many of the myths and mysteries sur-rounding it have gone. It is now known that, although the experience and in-tensity of orgasm may vary considerably, the actual physical process of or-gasm is always the same. The distinction between "vaginal" and "chtoral" orgasm is a myth. REACHING ORGASM Women vary greatly in what they respond to sexually, but the mons pubis, labia minora, clitoris and vaginal entrance are almost always important. The clitoris is the most sexually responsive part of a woman's body, and in most cases fairly continuous clitoral stimulation is needed for orgasm. However, * From Woman's Body: An Owner's Manual by the Diagram Group � 1977 The Diagram Group, published by Paddington Press. since the tip of the ditoris is extremely sensitive, constant direct touch, can become painful. So, for the majority of women, manipulation of the whole genital area is more pleasurable. During intercourse, movement of the penis in and out of the vagina provides continual clitoral stimulation by moving the labia minora backward and forward over the clitoral tip. The anus is another potentially erotic area, but it is not as easily penetrated as the vagina. For anal intercourse, lubrication-K-Y jelly, for example-is generally needed. THE FEELING OF ORGASM The time needed to reach orgasm varies from woman to woman and from occasion to occasion. Just before orgasm there is a feeling of tension lasting possibly 2 to 4 seconds when all the small muscles of the pelvis surrounding the vagina and uterus contract. This is followed by the orgasm itself, which may last 10 to 15 seconds. It is felt as a series of rhythmic muscular contrac-tions, occurring every 0.8 seconds, firstly around the outer third of the vagina and spreading upward to the uterus. Both uterus and rectum also contract In a mild orgasm there may be 3 to 5 contractions; in an intense one, 8 to 12. Also during orgasm the muscles of the abdomen, buttocks, arms, face, legs and neck may contract. Breathing is more rapid and blood pressure climbs. All these return to normal and orgasm is usually followed by feelings of relaxation and peace. MULTIPLE ORGASM Women, unlike men, are capable of multiple orgasm. That is, immediately or shortly after a first orgasm, if a woman maintains her sexual excitement at the plateau level, she can move directly into a second orgasm. Some women can experience 3 or 4 orgasms within a few minutes, and up to 12 in one hour have been recorded. EXPERIENCE OF ORGASM Virtually all woman are physically able to attain orgasm. But a recent sur-vey, the Hite Report, suggests that as few as 30 percent regularly achieve or-gasm through intercourse. Kinsey's data indicates that such orgasm does gradually become more frequent in long-term relationships but that even after twenty years of a relationship 11 percent of women never reach orgasm. Nevertheless, it seems that the vast majority of women prefer intercourse to any other sexual activity because of the closeness and affection associated with it. Yet, despite the "sexual revolution" of the 1960s, women still seem to feel guilt about their own sexuality and are reluctant either to initiate sexual activity or to communicate their sexual needs to their partners. Male Orgasm Orgasm in males is the experience of maximum pleasure in the genital area at the point of ejaculation (discharge of semen). The normal male orgasm is a total experience involving both the body and the mind. To describe it adequately we must take up each aspect separately. First, the physical or body aspect. Orgasm in the male is a climax of a se-quence that begins with erection. The penis has numerous nerve endings, which, when stimulated, cause the penis to fill with blood and become erect (Stimulation of the penis is not the only way erection is achieved. Memories, fantasies, and seeing pictures of women and their bodies, reading erotic or pornographic literature also can produce an erection.) Erections occur even in infant boys, as every mother has observed. Erec-tions may also occur when the bladder is full. The penis frequently becomes erect during the night without direct stimulation. Erections are most frequent during adolescence, when the capacity for sex-ual arousal is greatest, but they are experienced throughout the life of a man, although the frequency lessens with age. If the exciting stimulation continues, there are changes in other parts of the body. There is more blood flow into the scrotum, prostate gland, and the tes-ticles. The skin temperature rises. Blood pressure goes up, and the heart beats faster. There is also a reflex tendency to engage in regular pelvic to- and-fro movements, forward and back. As the tension increases to the peak of pleasure, the orgasm itself (ejacula-tion of semen) occurs in a sequence of spasms involving the genital area and the pelvis especially, but may include the rest of the body, so that the trunk, legs and jaw may also be in spasm or at last be powerfully taut. Pelvic to-and-fro movement may also be seen in infants. Sometimes boys before puberty experience erection and ejaculatory spasms, but only after complete sexual maturity at puberty is semen ejaculated at the point of or-gasm. At the end of the ejaculation, which occurs in several spurts along with the spasms, there is a total relaxation of the body, including the penis, which quickly loses its erection. The individual usually feels relaxed and may want to sleep. Some young men sustain a partial erection and after 10 to 20 minutes begin the sequence which leads to another orgasm. The emotional experience which accompanies the physical changes begins with the males being excited by sexual pleasure. The pleasure is aroused by direct touching of his penis or other sensitive parts of the body. The keenest pleasure is felt in the penis itself. But touching of the hair, neck, ear lobes, or the skin of almost any part of the body (by the "right" person) is exciting. During the build-up phase, before the moment of orgasm, men may have fantasies of various kinds which are exciting. It does not matter what these fantasies (mental images) are as long as they are effective in maintaining the erection and achieving the orgasm. Sexual partners should not require that the fantasies be about themselves. Nor should the man feel it abnormal to fantasize about whatever arouses him. Young males are highly excitable and are less able to keep from having the orgasm than older men, who have learned to sustain their erections and pro-long the pleasurable period before orgasm and ejaculation. The orgasm as the maximum of physical pleasure provides a strong moti-vation for engaging in sexual intercourse so that man can reproduce. The ejaculation of semen (which contains the sperm) into the vagina makes fer-tilization a likelihood, especially during the time of the menstrual cycle when the female has released the ovum (egg) into her uterus. But men do not have to be conscious of nature's purpose to want to have intercourse. They are conscious of their desire to experience the orgasm. Adolescent boys, not ready for the complexities of relationships with females, and men without women for various reasons may achieve orgasm through masturbation. Spon-taneous orgasms may also occur at night (wet dreams). Usually, if orgasm is not reached by intercourse or masturbation, such spontaneous ejaculations at night are more frequent. Masturbation is therefore an available means for achieving orgasm and releasing the tension that builds up from being aroused sexually. Tensions build up psychologically for many other reasons which are not sexual, and the pleasure of orgasm may be used to relieve these tensions, too. In contrast to the belief of a century ago, we now know that masturbation to orgasm is beneficial psychologically. Masturbation prepares the young man for intercourse. Being able to gain pleasure by one's self prepares him to gain it with another. Of course, excessive masturbation (more than once or twice in a twenty-four hour period) may be a sign that the tensions which exist are not sexual and indicate emotional and psychological problems that require evaluation and perhaps treatment. While orgasm is not essential for life itself, the desire to have it is often so strong that not achieving it, especially in youth and adulthood, may be ex-tremely frustrating and depressing. There may be physical diseases which interfere with having orgasm, and if failure to achieve it persists, a physical examination is called for. But usually the failure to achieve orgasm is due to psychological causes. Occasional failures should be expected by males and their partners and should not be considered a sign that something is seriously wrong in either partner or in the relationship. Young couples are usually frustrated and upset by failure. Older couples, while they may be frustrated, learn to accept these episodes more philosophically. Continued inability to achieve orgasm either because of loss of erection or frequent prolonged erections without ejaculation should be considered a reason for investigation and possible treatment. Premature ejaculation (too early) is usually not accompanied by a full orgasm, and of course interferes with the achievement of satisfaction by the sexual partner. Again, occasional premature ejaculations are not to be considered a sign of physical or psycho-logical disease. One of the greatest advantages of a continued relationship with one sexual partner, as in marriage, is the partners learn about one another's special ways to reach orgasm. Persons who love each other and are comfortable and relaxed can be fully open and tell one another what works best in achieving orgasm. They can be considerate of each other's preferences, and accept each other's occasional failings. It is not necessary for the male or the female to have orgasm at exactly the same moment. It is also not necessary for physical and psychological health that the male have an orgasm every time he has sexual intercourse. If a male is aroused nearly to the point of orgasm but does not reach climax, he may feel an aching sensation in the testicles which subsides within an hour or so. There is no danger to his health from such frustrating, aching experiences, though they cause him to wish for relief. Consciously or unconsciously, reaching orgasm is felt as proof of maleness and therefore it is a source of masculine pride and self-esteem. Some males feel it necessary to make their sexual partners achieve orgasm before they do as proof of their ability to excite and satisfy a woman. Males are often extremely sensitive about their sexual capacity. If their sexual partners make insulting or deprecating comments about it, they are deeply hurt and often angered. When males do poorly at school, or in their jobs or are frequent failures or losers in competitive sports, wherever their pride or self-esteem is tested, they may turn to orgasm to relieve their ten-sions. The orgasm is felt to be necessary. Under these circumstances, how-ever, it is difficult to relax and the male is more apt to experience failure. In some men, orgasm is necessary to keep them feeling alive and whole and prevents depression and mental disorganization. Needless to say, these men need psychological or psychiatric help. They act as if they are desper-ately in need of sexual satisfaction and they make their partners unhappy through their excessive demands for sex. The male orgasm, as described so far, is the usual form in which orgasm takes place. However, there are many different ways that males use to achieve orgasm. These depend on the individual man and cannot be covered here. Some men are "loners" who prefer to achieve orgasm by themselves, with-out partners. Others are "gay" and prefer partners who are male. A man who cannot achieve orgasm in sexual intercourse should realize that he is not functioning according to nature's plan and should seek profes-sional help so he can enjoy the full pleasures of his maleness. How and where does one obtain this help? First, as mentioned earlier, he should get a thorough checkup to make certain there is no organic problem. Then he should see a psychiatrist, psychoanalyst or psychologist for an evaluation and treatment. Mental health clinics can provide counseling for a modest fee- sometimes no fee, in special circumstances. These clinics can be found by contacting the state or county mental health societies. One should beware of quack counselors who promise quick cures for sex- nal problems. In order to ascertain the reliability of a therapist, one should consult his own physician or the psychiatric department of a hospital. One may also call the Institute for Psychoanalysis if there is one in his city. They offer splendid referral service. Social workers and sex therapists are often extremely useful in helping with these problems, but they must be trained in the treatment of emotional prob-lems which include sexual dysfunctions. In order to check out any individual chosen to help with a sexual problem, one may contact the American Psychi-atric Association, the National Association of Social Workers, the American Psychological Association, the American Medical Association, or the Ameri-can Psychoanalytical Association. Their addresses may be obtained by calling the public library. In rare cases, a patient seeking help for a sexual problem may encoun-ter a psychiatrist, psychologist or therapist who suggests that the patient en-gage in sexual intercourse with him or her. Under no conditions should this be permitted. Such conduct is completely unethical and attempts at such bizarre behavior should be reported to the American Psychiatric Association, the American Psychological Association and the American Medical Associa-tion. credit: Dr. Morris A. Sklansky, Training Analyst, Chicago Institute for Psycho-analysis. The New English Dictionary defines pain as "the sensation one feels when hurt in body or mind." However, most people use pain to describe a distress-ing discomfort occuring in the body. Historians tell us that pain has afflicted mankind since the beginning of time. Through the ages there has been great disagreement on not only the cause of pain but also the proper treatment of it. The Greek philosopher Aristotle, like Plato before him, spoke of pain as the opposite to pleasure. This was the accepted explanation of many cen-turies. Interestingly, the word "pain" comes from the Latin word "poena," mean-ing punishment. It wasn't until 1840 that it was learned that specific nerve fibers carry pain messages. More recently pain was divided into two kinds, organic and psychogenic. The former was believed to be caused by a physical disorder of the body and the latter by a mental illness. Although this classification helped our understanding of pain by giving equal recognition to psychological as well as physical causes for the body distress, it also contrib-uted to a great deal of misunderstanding. Not infrequently when a doctor could not find a physical cause for a per-son's complaint of pain, he would assume that the cause was psychological and label the condition "psychosomatic." This diagnosis of pain when no or-ganic disease could be found not only lacks scientific foundation, but also was frequently incorrect. The diagnosis of psychosomatic pain must be based on positive findings of emotional problems. Some doctors, and even lay peo-ple, through their own frustration in attempting to deal with a patient with a pain problem, would not only label it psychogenic, but would go further and sometimes in a hostile way tell the patient that his pain was "all in his head." The patient, feeling rejected by these remarks, would go from doctor to doc-tor looking for someone who understood his problem. Unfortunately, the pa-tient, instead of finding an understanding, knowledgeable doctor, would often find someone who was willing to administer potentially destructive treatment (sometimes an operation) under the guise of "understanding" him. This confusion within the medical society and the public in general led to an increase in the most common illness in our society, iatrogenic disease. This disease, or illness, develops in the patient as a result of treatment by a doctor. It may be obvious as surgical complications or side effects of medi-cation. More frequently, however, it is manifested as fears, anxiety and depression instilled in the patient by a doctor who not only does not under-stand pain, but also does not understand the patient who is experiencing the pain. Fortunately misunderstandings about pain, in most cases, are not a part of modem day medicine. We now recognize that all pain is real. The causes of the pain are varied and complex and may include compli-cated physical dysfunctions as well as multiple emotional reactions. To fur-ther complicate the problem, each person's reaction to pain is uniquely different. These reactions are as varied as personalities and are determined by all of the individual's past experiences with pain. It is not unlike a computer with a memory bank of painful experiences telling us how to react, what to expect from others, and even how to feel in response to the current painful condition. It is this complex pattern that makes it so difficult for one human being to understand another human being's pain. It is the most difficult symp-tom to evaluate because the doctor must depend solely on the report of the patient and cannot measure pain by laboratory tests or X rays. Our present understanding of the equal importance of the organic condition, the memory bank of painful experiences, and the current stress associated with the pain have led to the present classification of pain and a more realistic treatment approach to the patient experiencing pain. There are two types of pain: acute or simple pain and chronic, complicated pain. Acute, simple pain is generally of short duration. There is very little stress associated with the cause and treatment of it. As a result, the individ-ual's personal reaction is minimal and, for all practical purposes, the pain memory bank is not called upon. Therefore, the patient does not overreact to pain. Basically the pain is not part of a threatening situation. Therefore, there is minimal fear, anxiety, tension, worry, anger, frustration, depression or withdrawal. The doctor generally has little trouble diagnosing the cause of the pain, and even less difficulty treating it. In many instances the body repairs itself without the need of medical inter-vention. Even when treatment is necessary, the response is excellent. In this type of pain there is very little if any risk in using the usual, customary treat-ment approaches to pain such as pain medications, surgery, immobilization of the part by splints, casts or bed rest, or other medical therapies. The reason these treatment approaches are almost always effective and seldom carry undue risk is because the patient's primary interest is relief of pain, re-covery from illness and resumption of normal functioning as soon as possi-ble. Acute simple pain serves a vital function. It tells us that something has gone wrong in the body or mind. Without it, we could not survive. Chronic complicated pain generally is longer in duration. It takes over the individual's functioning, both physical and emotional, thus dictating by its agony and misery the way the person lives and relates to others. With this type of pain, an individual frequently becomes a zombie on drugs, a mass of scars from unsuccessful operations, as well as a "pain" to everyone around him. It has been estimated that there are twenty million Americans living in chronic pain. Lost wages, medical expenses and workmen's compensation payments from this condition total somewhere between $35 billion and $50 billion a year. Back pain, the most common chronic pain condition, ac-counted for eighteen million physician office visits last year, while doctors spend twelve million hours of their time with patients having chronic head-ache. This adds up to a cost in suffering, dollars and physician time that we as individuals and as a nation cannot afford. One of the main reasons chronic pain has caused so much suffering and expense is that we have failed to recognize its existence. Based on the as-sumption that all pain responded to the same approach given acute pain, chronic pain sufferers not only received improper treatment, but the treat-ment, in many instances, further complicated the condition and made it worse. Pain always begins as a warning signal that something has gone wrong in the body or mind. If the signal is not heeded or is misperceived, in a very short time complications begin to develop. These complications lower the in-dividual's tolerance to pain, thus increasing its intensity. As the complications multiply and expand, the initial pain, which was only a warning signal, be-comes more intense and severe, affecting not only the person, but also those around him. The pain is often described in agonizing terms and becomes the main topic of conversation. This fixation is one of the early complications and one of the most disabling. The sufferer cannot concentrate on his work or activities and therefore withdraws from his social contacts. The pain has now become a "disease" and, as it becomes more severe, the individual frequently finds it necessary to decrease his activities. Complications that increase the severity of the pain are physiological, psychological, interpersonal, social and voca-tional. The physiological complications are frequently secondary to medical treatment. They consist of drug dependence and addiction, muscle weakness through prescribed rest, postoperative complications and dependence upon braces, crutches, etc. The psychological complications consist of anxiety, ten-sion, fear, worry, anger, frustration, depression, low self-worth and with-drawal. The personal complications are further compounded by the reaction of others. Initially the patient receives understanding and sympathy. This, in a sense, "rewards" the patient for being ill. He is catered to by his family and compensated for by his employer. There may even be financial rewards re-lated to pain caused by certain accidents. These secondary gains, as they are termed in the medical profession, may prolong the pain process without the patient's conscious knowledge. At this stage the patient has fallen into the vi-cious cycle of chronic pain. All of the above complications-physical, psy-chological, and interpersonal-lead to social withdrawal and a compounding of the pain syndrome. Since all the focus up to this point has been on the person in pain, the significant other people in his life are often overlooked. These family members and friends are frequently hurting as much as the patient because of their own experiences in relationship to him. The other person has not only had a major upheaval in his life because of what has happened to the person with pain, but he has also had to suppress feelings of anger and guilt which could not be expressed openly to the patient. People are afraid to tell the per-son with pain how angry they are with him because of the unwritten law that you cannot "hit" a person who is already down. Even having these feelings produces guilt in the other person. At this stage of the chronic pain syndrome, significant other people often reject the person with chronic pain, no matter how much they love him, in a desperate attempt to save themselves from further distress. Final and ultimate rejection felt by the person with chronic pain is the realization that society no longer wants or needs him as a worker no matter how effective he was at his job prior to the pain process. Compensation payments in dollars, although contributing to secondary gain, never compensates for the loss of self-worth experienced by the individual who is told he is no longer capable of making a contribution to society. Obviously, the best treatment of this chronic compli-cated pain syndrome is to prevent its occurrence. This can only be done if all of those involved with the person at the onset of pain, including the person himself, recognize that the potential for chronic pain exists in every pain process. The physician's role in prevention is to treat the whole person and not just the painful part. With modem medical technology, there has been a tend-ency for doctors to specialize to the point where they fail to recognize that a human being is attached to part of the body that is in pain. Doctors should never treat a stranger. By spending time with the patient and his family, fa-miliarizing himself with the patient's needs, his reaction to stress, his old pain patterns, and the family's reaction to the patient in his painful condition, the physician can prevent chronic pain. Family members can play their part in avoiding chronic pain by dealing openly and honestly with the patient. He needs continued involvement in the family unit and in the role with which he is familiar to maintain his self- worth. The employer can play his role in preventing disability by providing a flexible work situation. This will allow the employee to maintain a positive at-titude about his job. His return to work as a productive individual will help him maintain self-worth and avoid chronic pain. Most of all, the patient can avoid the development of chronic, complicated pain by keeping open com-munication with his family, friends, physician and employer. It is important for him to trust a competent physician and not doctor-shop when his physi-cian tells him what he does not want to hear. He must also recognize that being cared for by others eventually leads to loss of independence and lowered self-worth. By resisting the temptation to go for the easy dollar through workmen's compensation, disability insurance or a court suit, dignity is main-tained and chronic pain is avoided. If, for whatever reason, prevention fails, and an individual develops chronic, complicated pain, all is not lost. There are now available, through-out the country, pain clinics that approach the pain problem by treating the whole person. The focus of treatment is to eliminate the complications and promote healthy living, thus decreasing the pain intensity. Therapeutic tools used in these clinics are those which increase relaxation, strengthen muscles, and increase activity, achieve healthy communication, and discontinue the use of addictive or habit-forming drugs. In these programs, healthy behavior is fostered while pain behavior is not rewarded. The most essential force in these programs that leads to healthy living is a trust relationship built up between the patients and the staff. A strong bond also develops among the patients who are all working toward healthy goals. Family involvement is essential to develop healthy communication. A patient must spend weeks or months in a pain rehabilitation program to escape from the chronic pain syndrome, but this is a brief interlude compared to a lifetime of agony. God gave us pain to protect us from danger. It was never meant to be a disability. The International Association for the Study of Pain and the American So-ciety of Anesthesiologists are both compiling a catalogue of accredited pain clinics. This has become necessary because scores of pain clinics that offer nothing more than the old-fashioned, outdated treatment approach under a new name have sprung up around the country. Some pain control centers have gone so far as to offer the unwary public pain control methods adminis-tered by unskilled personnel without adequate medical supervision. Some of the so-called pain clinics have a medical doctor listed as director when he does no more than collect a fee for the use of his name. Until an up-to-date list of reliable pain clinics is available, the unwary pub-lic is vulnerable to the quackery that will always be present when money can be made by dishonest people who exploit the suffering of others. A reliable pain clinic that approaches chronic pain by treating the whole person can generally be found by contacting the County or State Medical Society or the American Medical Association. An individual's family physician has fre-quently had other patients successfully treated in a comprehensive pain clinic and can also be of assistance. Listed below are accredited pain clinics that recognize the need to treat the whole person. If one of these clinics is not in your area, write to the nearest one and they can probably refer you to a simi-lar clinic near you. It is very important to adequately evaluate a pain clinic's treatment program before entering treatment. Investigate and ask questions. Persons suffering from chronic pain can ill afford another frustrating failure, with the added risk of more complications to intensify the pain even further. COMPREHENSIVE PAIN CLINICS Arizona The Center Mesa Lutheran Hospital 501 West Tenth Place Mesa, Arizona 85201 Telephone: (602)834-1211, Ext 2175 Chief of Center: Neal Olshan California Pain Center City of Hope National Medical Center 1500 East Duarte Road Duarte, California 91010 Telephone: (213)359-8111 Directors: Benjamin L. Crue, M.D., and lack J. Pinsky, M.D. Pain Treatment Center Hospital of Scripps Clinic La Jolla, California 92037 Telephone: (714)459-2390 Directors: Richard A. Stembach, Ph.D., and Donald J. Dalessio, M.D. UCLA Pain Management Clinic UCLA School of Medicine 10833 Le Conte Avenue Los Angeles, California 90024 Telephone: (213)825-0779 Director: Verne L. Brechner Georgia Emory University Pain Clinic Clifton Road Atlanta, Georgia 30322 Telephone: (404)377-9111, Ext. 375 Director: Steven F. Brenna, M.D. Illinois Pain Center Rush Medical College Rush Presbyterian St. Luke's Medical Center 1725 West Harrison Street Chicago, Illinois 60612 Telephone: (312)942-6631 Director: Max S. Sadove, M.D. Maryland Pain Clinic Johns Hopkins University School of Medicine Baltimore, Maryland 21205 Telephone: (301)955-6405 Directors: Donlin M. Long, M.D., and Richard G. Black, M.D. Massachusetts Pain Unit Massachusetts Rehabilitation Hospital 125 Nashua Street Boston, Massachusetts 02114 Telephone: (617)523-1818 Director: Gerald M. Aronoff, M.D. Minnesota Minneapolis Pain Clinic 4225 Golden Valley Road Minneapolis, Minnesota 55422 Telephone: (612)588-0661 Director: Loran F. Pilling, M.D. Pain Rehabilitation Program Metropolitan Medical Center 900 South Eighth Street Minneapolis, Minnesota 55404 Telephone: (612)347-4506 Director: Loran F. Pilling, M.D. Pain Clinic University Hospital University of Minnesota Mayo Building Minneapolis, Minnesota 55455 Telephone: (612)373-8205 Directors: Donald Erickson, M.D., and Allan Roberts, Ph.D. Pain Management Center Mayo Clinic-St. Mary's Hospital of Rochester Rochester, Minnesota 55901 Telephone: (507)282-2511 Director: David W. Swanson, M.D. Nebraska The Nebraska Pain Rehabilitation Unit University of Nebraska College of Medicine 42nd Street and Dewey Avenue Omaha, Nebraska 68105 Telephone: (402)541-4301 Director: F. Miles Skultety, M.D. Oregon Portland Pain Rehabilitation Center Emanuel Hospital 3001 North Gantenbein Avenue Portland, Oregon 97227 Telephone: (503)280-4404 Director: Joel L. Seres, M.D. Virginia Nerve Block and Pain Studies Clinic University of Virginia Medical Center Charlottesville, Virginia 22903 Telephone: (804)924-5581 Director: Harold Carron, M.D. Washington Pain Clinic University of Washington School of Medicine Seattle, Washington 98195 Telephone: (206)543-2672 Director: John J. Bonica Wisconsin The Pain and Health Rehabilitation Center 615 South Tenth Street LaCrosse, Wisconsin 54601 Telephone: (608)786-0611 Director: C. Norman Shealy, M.D. credit: Loran Pilling, M.D., Minneapolis Clinic of Psychiatry and Neurology, Director of the Minneapolis Pain Clinic and Metropolitan Pain Rehabilitation Center, Minneapolis, Minnesota. Back Pain Although the term "Oh, my aching back" is attributed to the servicemen of World War II, people have been afflicted with low back pain for as long as people have been standing erect. It is, in fact, believed that this is the penalty humans must pay for standing on their two hind feet. Usually people who have low back pain have more anxiety about it than the condition actually deserves. Because of the myths, legal problems and work problems relating to the back, there is a poor understanding of the medical aspects of back pain. Because the spine performs the principal func-tion of body support, any problems relating to it may result in considerable anxiety. They can usually be controlled, however-especially conditions that deal with posture, exercise, obesity and emotional turmoil in our daily lives. To best understand spinal pain, it is necessary to know something about anatomy. The spine is made up of twenty-six bones stacked like blocks (these are called vertebrae) separated by a cushion or shock absorber (intervertebral disc). This forms the support beam for the rest of the erect body, to which is attached muscles, ligaments and ribs. These vertebra are divided into areas of the body, seven are involved in the neck, (cervical spine), twelve in the chest (dorsal or thoracic spine), five in the low back (lumbar spine), and the rest into the sacrum and tail bone (coccyx). Within the canal that runs through all of the bones (spinal canal), there is a tube, in which there is fluid and nerves (spinal cord). Between each set of vertebra, there is a pair of spinal nerves that go out to appropriate parts of the body. These nerves perform the function of supplying the muscles for movement and sensation to the skin as well as other parts of the body. Also connecting between the vertebra are lig-aments which help to support the body along with the muscles which cause the body to move. Because the cervical spine and lumbar spine are more mo-bile, they are subject to the increase of stresses and, consequently, account for most of the pain involved in the spine. When the nerve endings to mus-cles, skin, bone, joints, etc., are irritated in an abnormal way, sensations are sent back to the nerves, then to the spinal cord, and to the brain itself. The brain gets the message of irritation or injury, and it causes the body to react in such a way as to protect it. All of the parts involved in the spine can like-wise be irritated. All can react to these abnormal irritations. Regardless of cause of back strain, most of the discomfort that one experiences comes from stretching the ligaments, irritated joints, spasm of muscles, and pressure on nerves. Specifically, most of us have these symptoms because of back strain due to poor habits of bending or picking up objects, poor body mechanics in walk-ing and sitting. The same mechanics that cause pain in the above methods can result from injuries of any sort but may be even more pronounced be-cause they are sudden in nature. Another common cause of back pain is due to excess weight which is often accompanied by poor posture. Poor posture in those who are not overweight can cause chronic back pain if the abdominal muscles are weak. In today's society very few of us concentrate on abdominal muscle strength. We sit at desks, walk and work with our bellies literally hanging out. It is to this area that we must concentrate most of the treatment of back pain. The term that most of us are accustomed to hear is a "slipped disc." This is not a common cause for back problems, although most back pain is blamed on the "slipped disc." When one actually has a "slipped disc" (herniated nu-cleus pulposus) it is most likely to be accompanied by radiation of pain down the back of the thigh and leg and often to the foot, itself. It must be remem-bered that very few cases require surgery. The wear and tear of normal living may cause osteoarthritis, also known as degenerative arthritis. Most often this cannot be avoided, but this does not necessarily have to cause pain if one continues to observe the good practices of normal living. Anxiety is a common penalty for being alive. No one escapes it. Any sort of emotional stress can cause pain in various parts of the body, the back being one of the more common areas afflicted. When the doctor can find no organic reason for your back pain, it is wise to look for emotional reasons and work at eliminating the anxiety-producing problem. When looking for causes of pain in your back, your doctor will also look for the less frequent sources of pain. These include tumors (both benign and malignant), metabolic disorders, infections, congenital diseases and inflam-matory arthritis. If the back pain persists, it is wise to periodically recheck for any disease that might have developed since the first check. This is especially true where there has been a change in symptoms as well as a persistence or an increase in severity of symptoms. Because there are so many types of and causes for back ache, you must be aware of the doctor you turn to for an examination. Most commonly, this can be done through your own doctor, who, if he feels that he cannot find the cause, will probably refer you to a specialist. The specialist may be an ortho-pedic surgeon, a neurological surgeon, a neurologist or a physiatrist. It is important in an examination that the doctor obtain a thorough history of the problem, the nature of the pain, the severity of the pain, the length of time it has been present, as well as a history of previous X rays, laboratory work and treatment. After this is done, the physical examination can help the physician determine whether or not the pain involves the nervous system or is a mechanical type of painful problem. This not only includes examination of the muscles and bone structure, but must also involve other sources of back pain. Because the history and physical examination alone cannot give the final diagnosis, it is necessary for the doctor to have various blood and urine tests and X rays in order to make an accurate diagnosis. It might be neces-sary to proceed to other types of special studies such as electromyography to test whether the muscles of the body are involved, or the insertion of a dye into the spinal column (myelogram) to see if there is pressure on a nerve. Other tests that can be performed are bone scans, computerized axial tomography (CAT scan) and lumbar venograms. More than likely, the end result of the examination will be that of a chronic or acute back strain or irri-tation or arthritis, or some benign growth. It is to these areas that we direct our recommendations for treatment. The more one understands the princi-ples of treatment, the better he will be able to cope with the periodic or con-stant discomfort. In acute back pain, relief is usually obtained from bed rest, mild sedatives for a short period of time, a firm mattress and occasionally the injection in the painful areas with local anesthetics and/or steroids. The corset, or back brace, is meant to be used only for the acute phase of the pain. Wearing it beyond that point promotes muscle weakness. The time limit is generally no more than six weeks. As soon as the acute pain phase is over, exercises can be started and it is to this point that I would like to direct the principle of treatment. This may cause a controversy between various doctors and physical therapists. I firmly believe that sit-ups and toe-touching exercise should not be done. There are many substitutes for these exercises and one can achieve the same results without taking the risk of rekindling the original irritation. Almost anyone who walks, stands, gets in and out of cars, or exhibits any other normal back support system does not have to develop the "back" muscles but must con-centrate on the abdominal muscles. These can be done isometrically. That is, by tensing the muscles without going through the great range of motion of the spine. Included in the exercise program are those activities of daily living that one must learn how to do. For example, when lifting, one must bend from the knees and lift with arms and legs, rather than with the back. In standing or walking, it is good to walk with the pelvis tilted forward. When standing for long periods of time one should elevate one foot by using a foot stool or other device to relieve the stress on the back. For people who work at desks one must regulate the height of the desk and the height of the chair so that the feet, knees and hips are comfortable when sitting for long periods of time. This also applies to driving. The bucket seat position is often uncomfortable, whereas with the car seat moved forward and the knees bent properly, drivers are more comfortable. Since one third of our lives is spent in bed, the importance of a firm mat-tress cannot be overemphasized. Too often, we compensate for mattresses by telling patients to use a bedboard. It is more important to have the firmness next to the patient's body and not eight or ten inches away from it. If addi-tional support is needed, it is probably wise to use a pillow under the knees or to sleep on the side in a knees-up position. Sleeping on one's abdomen often causes additional stress on the back. Women who wear high heels (often the slender "fashionable" kind) for long periods of time risk falling down stairs. They also throw their bodies out of line in a way that creates back aches. Exercises for the back should be done with regularity. It is better to do the exercises briefly three times during the course of a day than to do them violently a few times during the week. Exercises should become a permanent feature in one's daily lifestyle. One of the best back-strengthening exercises is to lie on one's back and place a small sponge in the low back area. When one can press the sponge down to the floor, thereby completely flattening out the "sway-back," the ab-dominal muscles will tense up noticeably. It is this exercise that will help most in building up strength in this area and eliminate a good many back aches. credit: Robert G. Addison, M.D., Rehabilitation Institute of Chicago, North-western University Medical School, Director of Low Back and Pain Clinic. Paranoia Literally, this word of Greek derivation means a state of being "beside one's mind." The term denotes a disease also known as true paranoia and is fortu-nately very rare. It manifests itself in gradual development of an intricate, complex and elaborate, often logical system of thought based on a false premise. An illustration of paranoia is the story of the farmer who loved his animal stock dearly and one day decided to wean his horse from eating. Each day he diminished the horse's ration of oats while he continued to take excellent care of the animal. He kept congratulating himself on how well the horse looked while it still worked every day. When the animal finally dropped dead, the farmer could not understand what happened. After all, he followed the pro-cedure of weaning to a tee. Why did the horse die? A good case of paranoia is rare and difficult to find even for teaching pur-poses. St. Elizabeth's Hospital in Washington, D.C., usually has a few cases at hand because the city, being the seat of the United States Government, at-tracts paranoiacs who have developed a "better system" of governing and in their zeal to promote it come to the Capitol and eventually land in a psychi-atric hospital. They often have intelligent, persuasive and charismatic person-alities and easily attract followers, are extremely sensitive, jealous, suspicious and consider themselves endowed with unique and superior abilities. Once in power, they are ruthless. Despite their particular paranoid system, their thinking and personality traits remain intact. The history of mankind is full of despots, tyrants and dictators who were or are paranoids. A true paranoiac can be recognized by his "cause," very often political or religious. He needs people to follow him and is often seen in public places and squares proselytizing, discussing and arguing his point of view. He is rigid, self-righteous and cannot accept opposing views. He often loses his temper and gets into fights. He participates in plots and counterplots which may involve murder. This is how he comes to the attention of the police and is sent for psychiatric examination. Those whose diagnosis is true paranoia are kept in mental hospitals and those who are dangerous may, after trial, be sent to prisons for the insane where a program of treatment and rehabil-itation is designed for them. Treatment is difficult because as a rule they do not co-operate, simply be-cause they cannot accept the fact that they are sick. Therapy consists of tran- quilizing medication, electroshock and individual and group psychotherapy, usually a combination of all these modalities. Occasionally lobotomy (cutting of certain pathways in the brain) is recommended in some violent cases when everything else has failed. In addition to paranoia as a disease one must be aware of paranoid trends and symptoms in other psychiatric conditions and pathological states and even in non-pathological conditions. There is a type of schizophrenia (split personality) in which paranoia trends predominate in the form of persecutory or grandiose delusions. Perse-cutory hallucinations are a frequent companion. Excessive religiosity may be an important factor. These people are usually hostile and aggressive. The paranoid schizophrenic does not show the usual personality disorganization and deterioration present in other forms of schizophrenia. It is as if their par-anoia serves as a unifying factor which holds the personality together. Paranoid states occur frequently in the older age group and are completely reversible with proper help. Irritability, accusatory trends, ideas of persecu-tion, stubbornness, suspiciousness of friends and relatives are the main symp-toms. They may appear after the loss of an important person. Once these symptoms show up, professional help is indicated. Lastly, it is worthwhile mentioning that even in emotionally healthy and functioning individuals an occasional transitory paranoid episode may take place that does not require professional intervention. Any person under stress may develop a nagging suspicion lasting for hours and even days that he has been betrayed by a friend, lover, even spouse because an untoward event took place in his life, such as losing a job or not getting a promotion, etc. Brooding and exaggeration of a "case" against the alleged perpetrator follow. Plans of revenge are put together. But as the stress abates the person realizes that his suspicions and schemes were without foundation. What all this indi-cates is that paranoid mental mechanisms are an important way to protect the oneness of the self and are automatically used by the individual when flooded by stress and anxiety. The important thing about paranoia in general is to remember that besides becoming at times a severe mental illness which may endanger the life of the carrier as well as the lives of people at large, it also has the function of hold-ing the personality together and avoiding its complete disintegration. An outstanding characteristic of the paranoid symptom is that an unpleas-ant and threatening situation which is too much to handle is put outside of the individual and projected onto another individual. It is not I who hate him but it is he who hates me. In a simplified way, it is the pot that calls the kettle black. Finally, though the severe paranoid disorders are difficult to treat, they constitute a tiny minority compared with the huge majority of benign para-noid states and conditions which either subside on their own or can readily be treated in a brief period of time. credit: Samuel L. Safirstein, M.D., New York, New York, Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York, New York; Associate Attending, Department of Psychiatry, Mount Sinai Hospital, New York, New York. Parenthood: Guidelines to Help You Live Through It* All parents believe in heredity until a child of theirs begins to act a little goofy. If your children are beautifully adjusted, totally reliable, consistently obedient, co-operative, respectful, courteous, considerate and have never caused you a moment's trouble, you should be on display at the Smithsonian. * Reprinted from June 1968 issue of Family Circle magazine, � 1968 The Family Circle, Inc. If, on the other hand, there are times when your children annoy you, ex-haust you, worry you and cause you to wonder what in heaven's name you're doing wrong, join the club. The painfully embarrassing truth is that we are living in a child-dominated society. We have allowed our kids to take us over. Those of us who are past forty have witnessed a dazzling historical triple pass. In our growing-up years Father was the undisputed head of the house. With the advent of World War n, Mother displaced Father. And now, in far too many families, the kids are clearly in control. They direct the family's activities to an alarming degree. Whole communities are geared to their "needs." The junior members, more often than not, decide where the family will live, where it will vacation, what kind of car Dad will buy, and what brand of cereal, soap and toothpaste Mother will put in her shopping cart. Child guidance has taken on a new meaning: Parents are being guided by children. This is a strange phenomenon indeed, when one views the sociological his-tory of man. The concept of a child-centered family was virtually unheard of until recently. What is the reason for this unnatural chain of command? Par-ents are afraid to say no, afraid to give orders, afraid to punish because they fear the loss of love or they want to avoid an unpleasant confrontation. Moreover, the shakier the marriage, the more marked the abdication of parental responsibility. The woman who feels that her husband does not love her tries to get her children to love her twice as much by being permissive and wildly generous. The husband who feels rejected plays the same game, particularly with his daughters. Children are acutely sensitive to these machi-nations and learn quite promptly how to make parental insecurity pay off in gifts and unearned privileges. We have before us the depressing spectacle of millions of frightened and groveling parents, haunted by the ghosts of Adler and Freud, knocking them-selves out to be "nice" trying to relate to their kids in Meaningful Ways, competing for approval, and making incredible financial sacrifices so their children will have every known advantage-and some advantages never heard of outside the United States. Show me a family run by children, and I will show you a set of embattled parents trying to buy love. What a sorry sight-and some of us need go no farther than the mirror. Love, as viewed by the poets, may be a many-splen- dored thing, but the quest for love can result in considerable heartache. When we try to buy love, the price goes up, as it does with other commodi-ties. The child who senses that his parents feel guilty about leaving him with a sitter and a TV dinner will not hesitate to raise the price of "forgiveness." Then, after he has collected his ransom, he will think up something else to be angry about so he can collect again. Emotional blackmail can be a profitable business. In my opinion the theory of permissive upbringing was the most damaging concept ever latched on to by a generation of mixed-up parents. This "exper-iment" produced a shocking number of disturbed kids, plus countless nervous wrecks who had hoped to be teachers but turned to other careers because they couldn't stand the spoiled brats. In Dr. Lee Kanner's book for laymen entitled In Defense of Mothers, he describes permissive upbringing as an unnatural and antihuman scheme. Writes Dr. Kanner: "There is no air-raid shelter to protect us from the verbal bombs that rain down on contemporary Mom and Dad. At every ton they are assaulted by unfamiliar words and phrases which confuse and frighten them. Words such as Oedipus complex, maternal rejection, sibling rivalry, schizoid personality, regression, aggression, blah-blah-blah, and more blah." I applaud Dr. Kanner's statement and wish to add to it. My comments, however, are for both Mother and Father: Remove the rose-colored glasses, folks. They contain no correction for parental myopia. What the vast major-ity of American children need is to stop being pampered, stop being in-dulged, stop bing chauffeured, gifted, catered to and made to feel the world belongs to them and they are doing their parents a favor by letting them live in it Don't be afraid to be boss. Children are continually testing, attempting to see how much they can get away with-how far you will let them go-and they secretly hope you will not let them go too far. Be aware of this testing mechanism the next time you are locked in bitter debate with your teenager. And don't bug out when the crunch comes. The parent who tries to curry the favor of his child by giving him every-thing he asks for and letting him do as he pleases loses out on all fronts. He does not gain his child's goodwill or affection. He is despised for his gut-lessness and in the end blamed when there is trouble. "Why did you let me do it?" the child demands to know. "Because you begged me-you wanted to" is the feeble response. Then comes the most devastating blow. "You should have said no. What kind of parent are you, anyway?" Accept the fact that there will be moments when your children will hate you. This is normal and natural. But how a child handles hate may determine whether he will go to Harvard or San Quentin. A child should be taught to vent his anger in socially acceptable ways-ways that will not injure others, damage property or hurt his own self-esteem. Rules should be established and limits set-in writing, if necessary. I cannot emphasize too strongly the importance of setting limits. The child who knows just exactly how far he can go is relieved of a heavy burden. In our family the rules were simple: Get as mad as you like but there must be no hitting, no yelling, swear-words (so loud that the neighbors will hear) and no breaking anything you aren't prepared to pay for. Finally, remember that parents have rights and, like other rights, they must be exercised or they will be lost by default. If there is a question as to whether you should give the edge to your child or take it for yourself, I say take it for yourself. And don't feel guilty. Rank hath its privileges. Children need to practice the art of giving-and who is more deserving of considera-tion than one's own parents? An important parental right is privacy. Teach your children to mind their own business. If you want them to grow up with integrity and high principles, demonstrate these qualities in your daily life, and your youngsters will follow in your steps. The most important parental right is to have a life of your own. A man and his wife should enjoy a special relationship separate and apart from their children. Parents should have fun together, evenings-just the two of them. They must never lose sight of the fact that they started together as sweet-hearts, and one day their children will be gone, and they will be alone. Parents who genuinely love their children will insist on their rights and will give their children the rights that are theirs. Love is not a grasping, greedy thing that hangs on. It is a generous, lovely thing that lets go. In the final analysis, it is not what you do for your children but what you have taught them to do for themselves that will make them successful human beings. A PRAYER FOR PARENTS Oh, God, make me a better parent Help me to understand my children, to listen patiently to what they have to say and to respond to their questions kindly. Keep me from interrupting them, talking back to them and contra-dicting them. Make me as courteous to them as I would have them be to me. Give me the courage to confess my sins against my children and ask them for forgiveness when I know I have done wrong. May I not vainly hurt the feelings of my children. Forbid that I would laugh at their mistakes, or resort to shame and ridi-cule as punishment Let me not tempt a child to lie or steal. Guide me hour by hour that I may demonstrate by all I say and do that honesty produces happiness. Reduce, I pray, the meanness in me. May I cease to nag; and when I am out of sorts, help me, 0 Lord, to hold my tongue. Blind me to the little errors of my children and help me to see the good things they do. Give me a ready word for honest praise. Help me treat my children as those of their own age. Let me not expect from them the judg-ment of adults. Allow me not to rob them of the opportunity to wait upon themselves, to think, to choose and to make their own decisions. Forbid that I should ever punish them for my selfish satisfaction. May I grant them all their wishes that are reasona-ble and have the courage always to withhold a privilege which I know will do them harm. Make me so fair and just, so consid-erate and companionable, that they will have genuine esteem for me. Fit me to be loved and imitated by my children. Oh, God, do give me calm and poise and self-controL Ann Landers Parenthood: What Do You Owe Your Children?* If I were asked to select the one word that best describes the majority of American parents, that word would be guilt-ridden. Every day I receive an unending stream of mail and each family has a different story to tell. But the message is almost always the same: "We blew it." Beleaguered Mom and Dad, in their hairshirts from Saks and Sears, tell me they did their best but "something went wrong." A mother from El Paso confesses, "I was too permissive." A father from Kansas City laments, "I was too strict." From Scarsdale, both parents write: "We paid over $22,000 for psychiatric help for our three daughters. Now two of them aren't speaking to us. I wish * Reprinted from November 1977 issue of Family Circle magazine, � 1977 The Family Circle, Inc. we'd spent the money on a boat instead, and raised our kids the way we were raised." Wherever you look you see parents walking on eggshells, bending over backward to relate to their children in "meaningful" ways. They hunger for approval, make outrageous financial sacrifices so their children will have every known advantage and some advantages never before heard of outside of the United States. Love's magic spell may be everywhere, but when you try to buy it, the price goes up, as it does with any other commodity. Emotional blackmail can be a highly profitable business, especially when the buyer is loaded with guilt. How sad it is to see parents turning into willing victims of the "gimmee" game, complying with every request, large and small, only to discover that no matter what they do, it isn't enough. Attempts to curry favor lead only to a barrage of new requests. In the end, parents are despised for their gutlessness and blamed when there's trouble. The results of the General Mills American Family Report (1976-77) con-ducted by Yankelovich, Skelly and White, Inc., would have knocked the av-erage reader cranksided, but it produced no surprises for me. The study was based on interviews with 1,230 families who are raising children in a chang-ing society. It dealt with a re-examination of lifestyles and traditional values that place greater emphasis on sexual freedom, self-fulfillment, the blurring of the male and female roles, less conformity and more openness and frankness. Fifty-seven percent of parents interviewed fell into the category of "Tradi-tionalists." They firmly believe in religion, marriage as an institution, saving money and hard work. These parents want their children to be outstanding and are willing to make sacrifices in order to help them. Not far behind (43 percent) were the "New Breed Parents." They do not consider the institution of marriage all-important. They do not put as much weight on such values as religion, saving money, patriotism and success. "New Breed Parents" favor a permissive approach to child rearing and be-lieve that children should be free to make their own decisions. They do not feel that their children have any obligation to them later on in life. (This blew my mind.) Several authorities were asked to comment on the results of the study. Verle L. Nicholson, Director of Information for the President's Council on Physical Fitness and Sports, said, "The failure to provide discipline and di-rection and the anxiety about guiding children has created terrible problems." (He seems to have a firm grasp of the obvious.) Fred Hechinger of the Editorial Board of the New York Times said, "The general disappearance of widely agreed upon standards and values is ex-tremely dangerous to secure family life. It sets everyone adrift. Children have the least capacity to fashion their own rules." (Hello, Fred. So what else is new?) Precisely what did the study say to me? It said the same thing that Pve been saying to everyone these past twenty years: Parents had better get back to the traditional values and hang together... or they will hang separately. With these unsettling facts as a backdrop, I'll get down to the basic ques-tion: What do parents owe their children? It would be easier to start by tell-ing you what you do not owe them. You do not owe them every minute of your day or every ounce of your en-ergy. Nor do you owe them round-the-clock chauffeur service, baton-twirling lessons, horseback-riding lessons (and $90 boots), singing lessons, summer camp, ski outfits and ten-speed bikes, a Honda or a car when they turn six-teen. You don't owe them a trip to Europe when they graduate from high school. I take the firm, unpopular position that parents do not owe their children a college education, medical school, dental school or law school. If Bob or Betsy are serious students and have well-defined goals, if they consider higher education a privilege and not a right, by all means send them to college if you can afford it, but don't feel guilty if you can't. They don't have it coming. If they really want to go, they'll find a way. Student loans are available on a massive scale, and scholarships are plentiful for the bright and eager who can't afford to pay. After children marry, you do not owe them a down payment on a home or money for furniture. Nor do you have an obligation to baby-sit with their kids or take over when they go on vacation. If you want to do any of these things, it should be considered an act of generosity-but they have no right to take it for granted. Parents do not owe their progeny an inheritance no matter how much money they have. One of the surest ways to produce loafers and freeloaders is to let children know that their future is assured. The child who is goal- oriented and highly motivated will make it on his or her own, but there is no incentive like knowing it's the only way he or she is going to get there. Neces-sity is the best self-propelling agent of all. Unfortunately, the tax burden for the well-to-do makes trust funds a highly attractive alternative. Estate planners who work overtime (at $80 an hour) tell us one of the neatest devices to keep from giving it all to Uncle Sam is to set up a trust fund for the children. In my opinion, a far saner approach is to make a modest inheritance available when the child becomes thirty or thirty- five-with a stipulation that larger sums are available before that time in case of catastrophic illness or grave financial hardship. If the money is not used, it should be held over for educating the next generation-if there is a need-or given to a worthy charity. At this point you're probably wondering whether parents owe their chil-dren anything. My answer is, yes, they owe them a great deal. One of the chief obligations parents have to their children is to give them a sense of personal worth. Self-esteem is the cornerstone for good mental health. A youngster who is continually criticized and "put down," made to feel stupid and inept, constantly compared with brothers, sisters or cousins who do better, will not try to improve. On the contrary, he or she will be-come so unsure, so terrified of failing, that he or she won't try at all. When report cards are sent home, they'll read: "unmotivated,