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What is a Barbiturate?

Published on by Andrew Marshall17 Comments

Introduction

A barbiturate is a drug that acts as a central nervous system depressant.

Barbiturates are effective as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological addiction potential as well as overdose potential among other possible adverse effects. They have largely been replaced by benzodiazepines and nonbenzodiazepines (“Z-drugs”) in routine medical practice, particularly in the treatment of anxiety and insomnia, due to the significantly lower risk of addiction and overdose and the lack of an antidote for barbiturate overdose. Despite this, barbiturates are still in use for various purposes: in general anaesthesia, epilepsy, treatment of acute migraines or cluster headaches, acute tension headaches, euthanasia, capital punishment, and assisted suicide.

The name barbiturate originates from the fact that they are all chemical derivatives of barbituric acid.

Refer to Psycholeptic.

Brief History

Barbituric acid was first synthesized 27 November 1864, by German chemist Adolf von Baeyer. This was done by condensing urea with diethyl malonate. There are several stories about how the substance got its name. The most likely story is that Baeyer and his colleagues went to celebrate their discovery in a tavern where the town’s artillery garrison were also celebrating the feast of Saint Barbara – the patron saint of artillerymen. An artillery officer is said to have christened the new substance by amalgamating Barbara with urea. Another story was barbiturate was invented on the feast day of St. Barbara. Another story holds that Baeyer synthesized the substance from the collected urine of a Munich waitress named Barbara. No substance of medical value was discovered, however, until 1903 when two German scientists working at Bayer, Emil Fischer and Joseph von Mering, discovered that barbital was very effective in putting dogs to sleep. Barbital was then marketed by Bayer under the trade name Veronal. It is said that Mering proposed this name because the most peaceful place he knew was the Italian city of Verona.

It was not until the 1950s that the behavioural disturbances and physical dependence potential of barbiturates became recognised.

Barbituric acid itself does not have any direct effect on the central nervous system and chemists have derived over 2,500 compounds from it that possess pharmacologically active qualities. The broad class of barbiturates is further broken down and classified according to speed of onset and duration of action. Ultrashort-acting barbiturates are commonly used for anaesthesia because their extremely short duration of action allows for greater control. These properties allow doctors to rapidly put a patient “under” in emergency surgery situations. Doctors can also bring a patient out of anaesthesia just as quickly, should complications arise during surgery. The middle two classes of barbiturates are often combined under the title “short/intermediate-acting.” These barbiturates are also employed for anaesthetic purposes, and are also sometimes prescribed for anxiety or insomnia. This is not a common practice anymore, however, owing to the dangers of long-term use of barbiturates; they have been replaced by the benzodiazepines and Z-drugs such as zolpidem, zaleplon and eszopiclone for sleep. The final class of barbiturates are known as long-acting barbiturates (the most notable one being phenobarbital, which has a half-life of roughly 92 hours). This class of barbiturates is used almost exclusively as anticonvulsants, although on rare occasions they are prescribed for daytime sedation. Barbiturates in this class are not used for insomnia, because, owing to their extremely long half-life, patients would awake with a residual “hang-over” effect and feel groggy.

Barbiturates can in most cases be used either as the free acid or as salts of sodium, calcium, potassium, magnesium, lithium, etc. Codeine- and Dionine-based salts of barbituric acid have been developed. In 1912, Bayer introduced another barbituric acid derivative, phenobarbital, under the trade name Luminal, as a sedative-hypnotic.

Uses

Medicine

Barbiturates such as phenobarbital were long used as anxiolytics and hypnotics. Intermediate-acting barbiturates reduce time to fall asleep, increase total sleep time, and reduce REM sleep time. Today they have been largely replaced by benzodiazepines for these purposes because the latter are less toxic in drug overdose. However, barbiturates are still used as anticonvulsants (e.g. phenobarbital and primidone) and general anaesthetics (e.g. sodium thiopental).

Barbiturates in high doses are used for medical aid in dying, and in combination with a muscle relaxant for euthanasia and for capital punishment by lethal injection. Barbiturates are frequently employed as euthanising agents in small-animal veterinary medicine.

Interrogation

Sodium thiopental is an ultra-short-acting barbiturate that is marketed under the name Sodium Pentothal. It is often mistaken for “truth serum”, or sodium amytal, an intermediate-acting barbiturate that is used for sedation and to treat insomnia, but was also used in so-called sodium amytal “interviews” where the person being questioned would be much more likely to provide the truth whilst under the influence of this drug. When dissolved in water, sodium amytal can be swallowed, or it can be administered by intravenous injection. The drug does not itself force people to tell the truth, but is thought to decrease inhibitions and slow creative thinking, making subjects more likely to be caught off guard when questioned, and increasing the possibility of the subject revealing information through emotional outbursts. Lying is somewhat more complex than telling the truth, especially under the influence of a sedative-hypnotic drug.

The memory-impairing effects and cognitive impairments induced by sodium thiopental are thought to reduce a subject’s ability to invent and remember lies. This practice is no longer considered legally admissible in court due to findings that subjects undergoing such interrogations may form false memories, putting the reliability of all information obtained through such methods into question. Nonetheless, it is still employed in certain circumstances by defence and law enforcement agencies as a “humane” alternative to torture interrogation when the subject is believed to have information critical to the security of the state or agency employing the tactic.

Chemistry

In 1988, the synthesis and binding studies of an artificial receptor binding barbiturates by six complementary hydrogen bonds was published. Since this first article, different kind of receptors were designed, as well as different barbiturates and cyanurates, not for their efficiencies as drugs but for applications in supramolecular chemistry, in the conception of materials and molecular devices.

Sodium barbital and barbital have also been used as pH buffers for biological research, e.g. in immuno-electrophoresis or in fixative solutions.

Side Effects

There are special risks to consider for older adults, and women who are pregnant. When a person ages, the body becomes less able to rid itself of barbiturates. As a result, people over the age of sixty-five are at higher risk of experiencing the harmful effects of barbiturates, including drug dependence and accidental overdose. When barbiturates are taken during pregnancy, the drug passes through the placenta to the foetus. After the baby is born, it may experience withdrawal symptoms and have trouble breathing. In addition, nursing mothers who take barbiturates may transmit the drug to their babies through breast milk. A rare adverse reaction to barbiturates is Stevens-Johnson syndrome, which primarily affects the mucous membranes.

Tolerance and Dependence

Refer to Barbiturate Dependence.

With regular use, tolerance to the effects of barbiturates develops. Research shows tolerance can develop with even one administration of a barbiturate. As with all GABAergic drugs, barbiturate withdrawal produces potentially fatal effects such as seizures, in a manner reminiscent of delirium tremens and benzodiazepine withdrawal although its more direct mechanism of GABA agonism makes barbiturate withdrawal even more severe than that of alcohol or benzodiazepines (subsequently making it one of the most dangerous withdrawals of any known addictive substance). Similarly to benzodiazepines, the longer acting barbiturates produce a less severe withdrawal syndrome than short acting and ultra-short acting barbiturates. Withdrawal symptoms are dose-dependent with heavier users being more affected than lower-dose addicts.

The pharmacological treatment of barbiturate withdrawal is an extended process often consisting of converting the patient to a long-acting benzodiazepine (i.e. Valium), followed by slowly tapering off the benzodiazepine. Mental cravings for barbiturates can last for months or years in some cases and counselling/support groups are highly encouraged by addiction specialists. Patients should never try to tackle the task of discontinuing barbiturates without consulting a doctor, due to the high lethality and relatively sudden onset of the withdrawal. Attempting to quit “cold turkey” may result in serious neurological damage, severe physical injuries received during convulsions, and even death via glutamatergic excitotoxicity.

Overdose

Refer to Barbiturate Overdose.

Some symptoms of an overdose typically include sluggishness, incoordination, difficulty in thinking, slowness of speech, faulty judgement, drowsiness, shallow breathing, staggering, and, in severe cases, coma or death. The lethal dosage of barbiturates varies greatly with tolerance and from one individual to another. The lethal dose is highly variable among different members of the class, with superpotent barbiturates such as pentobarbital being potentially fatal in considerably lower doses than the low-potency barbiturates such as butalbital. Even in inpatient settings, the development of tolerance is still a problem, as dangerous and unpleasant withdrawal symptoms can result when the drug is stopped after dependence has developed. Tolerance to the anxiolytic and sedative effects of barbiturates tends to develop faster than tolerance to their effects on smooth muscle, respiration, and heart rate, making them generally unsuitable for a long time psychiatric use. Tolerance to the anticonvulsant effects tends to correlate more with tolerance to physiological effects, however, meaning that they are still a viable option for long-term epilepsy treatment.

Barbiturates in overdose with other CNS (central nervous system) depressants (e.g. alcohol, opiates, benzodiazepines) are even more dangerous due to additive CNS and respiratory depressant effects. In the case of benzodiazepines, not only do they have additive effects, barbiturates also increase the binding affinity of the benzodiazepine binding site, leading to exaggerated benzodiazepine effects. (e.g. If a benzodiazepine increases the frequency of channel opening by 300%, and a barbiturate increases the duration of their opening by 300%, then the combined effects of the drugs increases the channels’ overall function by 900%, not 600%).

The longest-acting barbiturates have half-lives of a day or more, and subsequently result in bioaccumulation of the drug in the system. The therapeutic and recreational effects of long-acting barbiturates wear off significantly faster than the drug can be eliminated, allowing the drug to reach toxic concentrations in the blood following repeated administration (even when taken at the therapeutic or prescribed dose) despite the user feeling little or no effects from the plasma-bound concentrations of the drug. Users who consume alcohol or other sedatives after the drug’s effects have worn off, but before it has cleared the system, may experience a greatly exaggerated effect from the other sedatives which can be incapacitating or even fatal.

Barbiturates induce a number of hepatic CYP enzymes (most notably CYP2C9, CYP2C19, and CYP3A4), leading to exaggerated effects from many prodrugs and decreased effects from drugs which are metabolised by these enzymes to inactive metabolites. This can result in fatal overdoses from drugs such as codeine, tramadol, and carisoprodol, which become considerably more potent after being metabolised by CYP enzymes. Although all known members of the class possess relevant enzyme induction capabilities, the degree of induction overall as well as the impact on each specific enzyme span a broad range, with phenobarbital and secobarbital being the most potent enzyme inducers and butalbital and talbutal being among the weakest enzyme inducers in the class.

People who are known to have committed suicide by barbiturate overdose include Charles Boyer, Ruan Lingyu, Dalida, Jeannine “The Singing Nun” Deckers, Felix Hausdorff, Abbie Hoffman, Phyllis Hyman, C.P. Ramanujam, George Sanders, Jean Seberg, Lupe Vélez and the members of Heaven’s Gate cult. Others who have died as a result of barbiturate overdose include Pier Angeli, Brian Epstein, Judy Garland, Jimi Hendrix, Marilyn Monroe, Inger Stevens, Dinah Washington, Ellen Wilkinson, and Alan Wilson; in some cases these have been speculated to be suicides as well. Those who died of a combination of barbiturates and other drugs include Rainer Werner Fassbinder, Dorothy Kilgallen, Malcolm Lowry, Edie Sedgwick and Kenneth Williams. Dorothy Dandridge died of either an overdose or an unrelated embolism. Ingeborg Bachmann may have died of the consequences of barbiturate withdrawal (she was hospitalised with burns, the doctors treating her not being aware of her barbiturate addiction).

Mechanism of Action

Barbiturates act as positive allosteric modulators and, at higher doses, as agonists of GABAA receptors. GABA is the principal inhibitory neurotransmitter in the mammalian central nervous system (CNS). Barbiturates bind to the GABAA receptor at multiple homologous transmembrane pockets located at subunit interfaces,[19] which are binding sites distinct from GABA itself and also distinct from the benzodiazepine binding site. Like benzodiazepines, barbiturates potentiate the effect of GABA at this receptor. In addition to this GABAergic effect, barbiturates also block AMPA and kainate receptors, subtypes of ionotropic glutamate receptor. Glutamate is the principal excitatory neurotransmitter in the mammalian CNS. Taken together, the findings that barbiturates potentiate inhibitory GABAA receptors and inhibit excitatory AMPA receptors can explain the superior CNS-depressant effects of these agents to alternative GABA potentiating agents such as benzodiazepines and quinazolinones. At higher concentration, they inhibit the Ca2+-dependent release of neurotransmitters such as glutamate via an effect on P/Q-type voltage-dependent calcium channels. Barbiturates produce their pharmacological effects by increasing the duration of chloride ion channel opening at the GABAA receptor (pharmacodynamics: This increases the efficacy of GABA), whereas benzodiazepines increase the frequency of the chloride ion channel opening at the GABAA receptor (pharmacodynamics: This increases the potency of GABA). The direct gating or opening of the chloride ion channel is the reason for the increased toxicity of barbiturates compared to benzodiazepines in overdose.

Further, barbiturates are relatively non-selective compounds that bind to an entire superfamily of ligand-gated ion channels, of which the GABAA receptor channel is only one of several representatives. This Cys-loop receptor superfamily of ion channels includes the neuronal nACh receptor channel, the 5-HT3 receptor channel, and the glycine receptor channel. However, while GABAA receptor currents are increased by barbiturates (and other general anaesthetics), ligand-gated ion channels that are predominantly permeable for cationic ions are blocked by these compounds. For example, neuronal nAChR channels are blocked by clinically relevant anaesthetic concentrations of both thiopental and pentobarbital. Such findings implicate (non-GABA-ergic) ligand-gated ion channels, e.g. the neuronal nAChR channel, in mediating some of the (side) effects of barbiturates. This is the mechanism responsible for the (mild to moderate) anaesthetic effect of barbiturates in high doses when used in anaesthetic concentration.

Society and Culture

Legal Status

During World War II, military personnel in the Pacific region were given “goofballs” to allow them to tolerate the heat and humidity of daily working conditions. Goofballs were distributed to reduce the demand on the respiratory system, as well as maintaining blood pressure, to combat the extreme conditions. Many soldiers returned with addictions that required several months of rehabilitation before discharge. This led to growing dependency problems, often exacerbated by indifferent doctors prescribing high doses to unknowing patients through the 1950s and 1960s.

In the late 1950s and 1960s, an increasing number of published reports of barbiturate overdoses and dependence problems led physicians to reduce their prescription, particularly for spurious requests. This eventually led to the scheduling of barbiturates as controlled drugs.

In the Netherlands, the Opium Law classifies all barbiturates as List II drugs, with the exception of secobarbital, which is on List I.

There is a small group of List II drugs for which doctors have to write the prescriptions according to the same, tougher guidelines as those for List I drugs (writing the prescription in full in letters, listing the patients name, and have to contain the name and initials, address, city and telephone number of the licensed prescriber issuing the prescriptions, as well as the name and initials, address and city of the person the prescription is issued to). Among that group of drugs are the barbiturates amobarbital, butalbital, cyclobarbital, and pentobarbital.

In the United States, the Controlled Substances Act of 1970 classified most barbiturates as controlled substances – and they remain so as of September 2020. Barbital, methylphenobarbital (also known as mephobarbital), and phenobarbital are designated schedule IV drugs, and “Any substance which contains any quantity of a derivative of barbituric acid, or any salt of a derivative of barbituric acid” (all other barbiturates) were designated as being schedule III. Under the original CSA, no barbiturates were placed in schedule I, II, or V; however, amobarbital, pentobarbital, and secobarbital are schedule II controlled substances unless they are in a suppository dosage form.

In 1971, the Convention on Psychotropic Substances was signed in Vienna. Designed to regulate amphetamines, barbiturates, and other synthetics, the 34th version of the treaty, as of 25 January 2014, regulates secobarbital as schedule II, amobarbital, butalbital, cyclobarbital, and pentobarbital as schedule III, and allobarbital, barbital, butobarbital, mephobarbital, phenobarbital, butabarbital, and vinylbital as schedule IV on its “Green List”. The combination medication Fioricet, consisting of butalbital, caffeine, and paracetamol (acetaminophen), however, is specifically exempted from controlled substance status, while its sibling Fiorinal, which contains aspirin instead of paracetamol and may contain codeine phosphate, remains a schedule III drug.

Recreational Use

Recreational users report that a barbiturate high gives them feelings of relaxed contentment and euphoria. Physical and psychological dependence may also develop with repeated use. Chronic misuse of barbiturates is associated with significant morbidity. One study found that 11% of males and 23% of females with a sedative-hypnotic misuse die by suicide. Other effects of barbiturate intoxication include drowsiness, lateral and vertical nystagmus, slurred speech and ataxia, decreased anxiety, and loss of inhibitions. Barbiturates are also used to alleviate the adverse or withdrawal effects of illicit drug use, in a manner similar to long-acting benzodiazepines such as diazepam and clonazepam. Often polysubstance use occurs and barbiturates are consumed with or substituted by other available substances, most commonly alcohol.

People who use substances tend to prefer short-acting and intermediate-acting barbiturates. The most commonly used are amobarbital (Amytal), pentobarbital (Nembutal), and secobarbital (Seconal). A combination of amobarbital and secobarbital (called Tuinal) is also highly used. Short-acting and intermediate-acting barbiturates are usually prescribed as sedatives and sleeping pills. These pills begin acting fifteen to forty minutes after they are swallowed, and their effects last from five to six hours.

Slang terms for barbiturates include barbs, barbies, bluebirds, dolls, wallbangers, yellows, downers, goofballs, sleepers, ‘reds & blues’, and tooties.

What is Active Listening?

Published on by Andrew Marshall1 Comment

Introduction

Active listening is a technique of careful listening and observation of non-verbal cues, with feedback in the form of accurate paraphrasing, that is used in counselling, training, and solving disputes or conflicts.

It requires the listener to pay attention, understand, respond and remember what is being said in the context of intonation, timing, and non-verbal cues (body language). This differs from other listening techniques like reflective listening and empathic listening.

Reflective listening is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. Empathic listening is about giving people an outlet for their emotions before being able to be more open, sharing experiences and being able to accept new perspectives on troubled topics that cause emotional suffering. Listening skills may establish flow rather than closed mindedness.

Brief History

Carl Rogers and Richard Farson coined the term “active listening” in 1957 in a paper of the same title (reprinted in 1987 in the volume “Communicating in Business Today”). Practicing active listening also emphasized Rogers’ (1980) concept of three facilitative conditions for effective counselling; empathy, genuineness, and unconditional positive regard. Rogers and Farson write: “Active listening is an important way to bring about changes in people. Despite the popular notion that listening is a passive approach, clinical and research evidence clearly shows that sensitive listening is a most effective agent for individual personality change and group development. Listening brings about changes in peoples’ attitudes toward themselves and others; it also brings about changes in their basic values and personal philosophy. People who have been listened to in this new and special way become more emotionally mature, more open to their experiences, less defensive, more democratic, and less authoritarian.”

Technique

Active listening comprises several components by the listener, who must pay attention to what the speaker is attempting to communicate and elicit clarification where necessary for comprehension.

Active listening involves the listener observing the speaker’s non-verbal behaviour and body language. The listener can observe non-verbal behaviours through kinesics, the study of body motion and posture; paralinguistics, the study of the tone of words; and proxemics, the study of physical distance and posture between speakers. Having the ability to interpret a person’s body language lets the listener develop a more accurate understanding of the speaker’s message.

Comprehending

Comprehension is a shared meaning between parties in a communication transaction. This is the first step in the listening process. The second step is being able to take breaks between discernible words, or talking segmentation.

Retaining

Retaining is the second step in the process. Memory is essential to the active listening process because the information retained when a person is involved in the listening process is how meaning is extracted from words. Because everyone has different memories, the speaker and the listener may attach different meanings to the same statement. Memories are fallible, things like cramming may cause information to be forgotten.

Responding

Active listening is an interaction between speaker and listener. It adds action to a normally passive process.

Assessment

Active listening can be assessed using the active listening observation scale (ALOS).

ALOS

The Active Listening Observation Scale (ALOS) was developed to measure the perceived or observed frequency of active listening enacted by physicians during patient consultations. Fassaert, van Dulmen, Schellevis, & Bensing (2007) provided evidence of adequate reliability estimates (α > .80) and construct validity for a 7-item version of the ALOS. Additional research has extended the ALOS to supportive listening contexts and provided evidence of appropriate reliability with 11 items (α > .90) as well as evidence of measurement model validity (Bodie & Jones, 2012). As of 2017, researchers are currently developing an extensive validity portfolio for the scale, particularly as an assessment of the occurrence of particular behaviours associated with active listening such as asking questions and displaying nonverbal understanding.

Other scales include:

  • Facilitating Listening Scale (FLS).
  • Active – Empathic Listening Scale (AELS).
  • Active Listening Attitude Scale (ALAS).

Refer to The Sourcebook of Listening Research: Methodology and Measures (25 August 2017) by Debra L. Worthington and Graham D. Bodie (Editors), published by John Wiley & Sons Inc.

Barriers to Active Listening

There are a multitude of factors that may impede upon someone’s ability to listen with purpose and intention; these factors are referred to as listening blocks. Some examples of these blocks include rehearsing, filtering, and advising. Rehearsing is when the listener is more focused on preparing their response rather than listening. Filtering is when a listener focuses only on what they expect to hear, while tuning out other aspects of what is being said, and lastly, advising is when the listener focuses on problem solving, which can create a sense of pressure to fix what the other person is doing wrong. Some barriers are due to hunger or fatigue of the listener, making them irritated and less inclined to listen to the speaker. Sometimes it is due to the language the speaker uses – such as high sounding and bombastic words that can lead to ambiguity. Other barriers include distractions, trigger words, vocabulary, and limited attention span.

Individuals in conflict often contradict each other. Ambushing occurs when one listens to someone else’s argument for its weaknesses and ignore its strengths. This may include a distortion of the speaker’s argument to gain a competitive advantage. On the other hand, if one finds that the other party understands, an atmosphere of cooperation can be created.

Shift Response

Shift response is the general tendency of a speaker in a conversation to affix attention to their position.[citation needed] This is a type of conversational narcissism – the tendency of listeners to turn the topic to themselves without showing sustained interest in others. A support response is the opposite of a shift response; it is an attention giving method and a cooperative effort to focus the conversational attention on the other person. Instead of being me-oriented like shift response, it is we-oriented. It is the response a competent communicator is most likely to use.

Understanding of Non-Verbal Cues

Ineffective listeners are unaware of non-verbal cues, though they dramatically affect how people listen. To a certain extent, it is also a perceptual barrier. Up to 93% of people’s attitudes are formed by non-verbal cues. This should help one to avoid undue influence from non-verbal communication. In most cases, the listener does not understand the non-verbal cues the speaker uses. A person may show fingers to emphasize a point, but this may be perceived as an intent by the speaker to place their fingers in the listener’s eyes. Overuse of non-verbal cues also creates distortion, and as a result listeners may be confused and forget the correct meaning.

Overcoming Listening Barriers

The active listening technique is used to improve personal communications in organizations. Listeners put aside their own emotions and ask questions and paraphrase what the speaker says to clarify and gain a better understanding of what the speaker intended to say. Distractions that interrupt the listener’s attention are one of the major barriers to effective listening. These include external factors such as background noise and physical discomfort, and internal distractions, such as thoughts about other things and lack of focus. Another barrier is misinterpretation of what the speaker is attempting to communicate, including assumption of motives, and “reading between the lines”, as is premature judgment of the speaker’s point, which can occur as a consequence of the listener holding onto a rigid personal opinion on the topic. This problem can be mitigated by asking the speaker what they mean when it is unclear, though this is not guaranteed to work every time. A strong disagreement hinders the ability to listen closely to what is being said. Eye contact and appropriate body languages are seen as important components to active listening, as they provide feedback to the speaker. The stress and intonation used by the speaker may also provide information to the listener, which is not available in the written word.

Applications

Active listening is used in a wide variety of situations, including public interest advocacy, community organising, tutoring, medical workers talking to patients, HIV counselling, helping suicidal persons, management, counselling and journalistic settings. In groups it may aid in reaching consensus. It may also be used in casual conversation or small talk to build understanding, though this can be interpreted as condescending.

A listener can use several degrees of active listening, each resulting in a different quality of communication.

The proper use of active listening results in getting people to open up, avoiding misunderstandings, resolving conflict, and building trust. In a medical context, benefits may include increased patient satisfaction, improved cross-cultural communication, improved outcomes, or decreased litigation.

Active Listening in Music

Active listening has been developed as a concept in music and technology by François Pachet, researcher at Sony Computer Science Laboratory, Paris. Active listening in music refers to the idea that listeners can be given some degree of control on the music they listen to, by means of technological applications mainly based on artificial intelligence and information theory techniques, by opposition to traditional listening, in which the musical media is played passively by some neutral device.

Criticism

A Munich-based marital therapy study conducted by Dr. Kurt Hahlweg and associates found that even after employing active listening techniques in the context of couple’s therapy, the typical couple was still distressed.

Active listening was criticized by John Gottman’s The Seven Principles for Making Marriage Work as being of limited usefulness:

Active listening asks couples to perform Olympic-level emotional gymnastics when their relationship can barely walk. . . . After studying some 650 couples and tracking the fate of their marriages for up to fourteen years, we now understand that this approach to counseling doesn’t work, not just because it’s nearly impossible for most couples to do well, but more importantly because successful conflict resolution isn’t what makes marriages succeed. One of the most startling findings of our research is that most couples who have maintained happy marriages rarely do anything that even partly resembles active listening when they’re upset.

Robert F. Scuka defends active listening by arguing that:

…a careful reading of the Hahlweg et al. (1984) study reveals that Gottman cites only certain (one-sided) results from the study. He also overlooks several important considerations that call into question his implied dismissal of the RE model as a legitimate therapeutic intervention for distressed couples.

What is the Family and Medical Leave Act of 1993?

Published on by Andrew Marshall1 Comment

Introduction

The Family and Medical Leave Act of 1993 (FMLA) is a United States labour law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons.

The FMLA was a major part of President Bill Clinton’s first-term domestic agenda, and he signed it into law on 05 February 1993. The FMLA is administered by the Wage and Hour Division of the United States Department of Labour.

The FMLA allows eligible employees to take up to 12 work weeks of unpaid leave during any 12-month period to care for a new child, care for a seriously ill family member, or recover from a serious illness. The FMLA covers both public- and private-sector employees, but certain categories of employees, including elected officials and highly compensated employees, are excluded from the law or face certain limitations. In order to be eligible for FMLA leave, an employee must have worked for the employer for at least 12 months, have worked at least 1,250 hours over the past 12 months, and work for an employer with at least 50 employees within a 75-mile radius. Several states have passed laws providing additional family and medical leave protections for workers.

Background

Prior to the 1992 presidential election, a family medical leave act had been vetoed twice by President George H. W. Bush. After Bill Clinton won the 1992 election, a law protecting family medical leave became one of his major first-term domestic priorities. Rapid growth in the workforce, including a large number of women joining, suggested a necessary federal regulation that would support the working class who desired to raise a family and/or required time off for illness related situations. President Clinton signed the bill into law on 05 February 1993 (Pub.L. 103–3; 29 U.S.C. sec. 2601; 29 CFR 825) to take effect on 05 August 1993.

The United States Congress passed the Act with the understanding that “it is important for the development of children and the family unit that fathers and mothers be able to participate in early childrearing … [and] the lack of employment policies to accommodate working parents can force individuals to choose between job security and parenting”. It also stressed the Act was intended to provide leave protection for individuals “in a manner that accommodates the legitimate interests of employers”.

On 20 December 2019, as part of the National Defence Authorisation Act (NDAA) for Fiscal Year 2020, the Federal Employee Paid Leave Act (FEPLA) amended the Family and Medical Leave Act (FMLA) to grant federal government employees up to 12 weeks of paid time off for the birth, adoption or foster of a new child. The law applies to births or placements occurring on or after 01 October 2020.

Contents

Scope of Rights

The Family and Medical Leave Act of 1993 generally applies to employers of 50 or more employees in 20 weeks of the last year. Employees must have worked over 12 months and 1250 hours in the last year (around 25 hours a week). However, employees are not eligible if they work at a work site where the total number of employees employed by the employer within 75 miles of that work site is less than 50. A worksite includes a public agency, including schools and state, local, and federal employers. The 50 employee threshold does not apply to public agency employees and local educational agencies. There are special hours rules for certain airline employees.

Employees must give notice of 30 days to employers if birth or adoption is “foreseeable”, and for serious health conditions if practicable. Treatments should be arranged “so as not to disrupt unduly the operations of the employer” according to medical advice.

Along with the 30 day notice, there are also other requirements to be made when seeking the FMLA rights. If an employee wants to leave the first time using ones FMLA rights, the person must first claim the Family and Medical Leave Act. In the case that an employee were to leave again under the FMLA act, the same process must proceed.

With the release of employees, there is a certification as well. The absence of an employee due to the conditions he or she may have may require a certification as proof of the verification of absence. In order to certify the leave of an employee, the employer may ask for other requirements. An example of these requirements are requiring multiple medical opinions. All of these prerequisites are at the employer’s expense. There are also certain rules that may apply to those who work at local education agencies.

Rights During Leave

Employees can have up to 12 weeks of unpaid leave for child birth, adoption, to care for a close relative in poor health, or because of an employee’s own poor health. In full, the purposes for leave are:

  • To care for a new child, whether for the birth, the adoption, or placement of a child in foster care;
  • To care for a seriously ill family member (spouse, son, daughter, or parent) (Note: Son/daughter has been clarified by the Department of Labour to mean a child under the age of 18 or a child over the age of 18 with a mental or physical disability as defined by the Americans With Disabilities Act, which excludes, among other conditions, pregnancy and post-partum recovery from childbirth);
  • To recover from a worker’s own serious illness;
  • To care for an injured service member in the family; or
  • To address qualifying exigencies arising out of a family member’s deployment.
  • Twenty-six workweeks of leave during a single 12-month period to care for a covered servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).

Child care leave should be taken in one lump, unless an employer agrees otherwise. If a father and mother have the same employer, they must share their leave, in effect halving each person’s rights, if the employer so chooses.

Employers must provide benefits during the unpaid leave. Under §2652(b) states are empowered to provide “greater family or medical leave rights”.

Since 2008, the Department of Labour has allowed the spouse, child, or parent of an active duty military member who is deployed overseas for 12 or more months to take up to 12 weeks of leave. Also, a military caregiver provision was added that would allow a caregiver to take up to 26 weeks of leave in order to actively care for a military member who requires medical attention for acute or ongoing conditions.

Substitute Leave

Under §2612(2)(A) an employer can make an employee substitute the right to 12 unpaid weeks of leave for “accrued paid vacation leave, personal leave or family leave” in an employer’s personnel policy. Originally the Department of Labour had a penalty to make employers notify employees that this might happen. However, five judges in the US Supreme Court in Ragsdale v Wolverine World Wide, Inc held that the statute precluded the right of the Department of Labour to do so. Four dissenting judges would have held that nothing prevented the rule, and it was the Department of Labour’s job to enforce the law.

Right to Return to Job

After unpaid leave, an employee generally has the right to return to their job, except for employees who are in the top 10% of highest paid and the employer can argue refusal “is necessary to prevent substantial and grievous economic injury to the operations of the employer.” In full, the rights during and after unpaid leave are to:

  • The same group health insurance benefits, including employer contributions to premiums, that would exist if the employee were not on leave.
  • Restoration to the same position upon return to work. If the same position is unavailable, the employer must provide the worker with a position that is substantially equal in pay, benefits, and responsibility.
  • Protection of employee benefits while on leave. An employee is entitled to reinstatement of all benefits to which the employee was entitled before going on leave.
  • Protection of the employee to not have their rights under the Act interfered with or denied by an employer.
  • Protection of the employee from retaliation by an employer for exercising rights under the Act.
  • Intermittent FMLA leave for their own serious health condition, or the serious health condition of a family member. This includes occasional leave for doctors’ appointments for a chronic condition, treatment (e.g. physical therapy, psychological counselling, chemotherapy), or temporary periods of incapacity (e.g. severe morning sickness, asthma attack).

“Highly compensated employees” have limited rights to return to their jobs. They are defined as “a salaried eligible employee who is among the highest paid 10 percent of the employees employed by the employer within 75 miles of the facility at which the employee is employed”. Their employers are not required to restore them to their original position (or an equivalent position with equivalent pay and benefits, as is guaranteed to other employees) if the employer determines that denying the employee their position is “necessary to prevent substantial and grievous economic injury to the operations of the employer” and the employer provides the worker with notice of this decision, though no time frame for providing this notice is established.

Enforcement

Employees or the Secretary of Labour can bring enforcement actions, but there is no right to a jury for reinstatement claims. Employees can seek damages for lost wages and benefits, or the cost of child care, plus an equal amount of liquidated damages unless an employer can show it acted in good faith and reasonable cause to believe it was not breaking the law. There is a two-year limit on bringing claims, or three years for wilful violations.

Non-Eligible Workers and Types of Leave

The federal FMLA does not apply to:

  • Workers in businesses with fewer than 50 employees (this threshold does not apply to public agency employers and local educational agencies as they are covered employers by name but there still must be at least 50 employees with a 75-mile radius for the employee to be eligible for FMLA leave);
  • Part-time workers who have worked fewer than 1,250 hours within the 12 months preceding the leave and a paid vacation;
  • Workers who need time off to care for seriously ill elderly relatives (other than parents), unless the relative was acting in loco parentis at the time the worker turned 18;
  • Workers who need time off to care for pets;
  • Workers who need time off to recover from short-term or common illness like a cold, or to care for a family member with a short-term illness;
  • Elected officials; and
  • Workers who need time off for routine medical care, such as check-ups.

State Family Leave

Some states have enacted laws that mandate additional family and medical leave for workers in a variety of ways. By 2016 four states had laws for paid family leave: California since 2002, New Jersey since 2008, Rhode Island since 2013, and New York since 2016. Washington state passed a paid family and medical leave law in 2007, but the law has not taken effect due to a lack of funding mechanism.

Dropping the Employer Threshold

The federal FMLA only applies to employers with 50 or more employees, within 75 miles. Some states have enacted their own FMLAs that have a lower threshold for employer coverage:

  • Maine: 15 or more employees (private employers) and 25 or more (city or town employers).
  • Maryland: 15 or more employees (private employers)Up to seven days for bone marrow donation. Up to 30 days for organ donation.
  • Minnesota: 21 or more employees (parental leave only).
  • Oregon: 25 or more employees. An employee must have worked at least 180 days, and averaged 25 hours per week at the time medical leave is requested
  • Rhode Island: 50 or more employees (private employers) and 30 or more employees (public employers).
  • Vermont: 10 or more employees (parental leave only) and 15 or more employees (family and medical leave).
  • Washington: 50 or more employees (FMLA reasons besides insured parental leave); all employers are required to provide insured parental leave.
  • District of Columbia: 20 or more employees.

Expanded Coverage

The federal FMLA only applies to immediate family – parent, spouse, and child. The 2008 amendments to the FMLA for military family members extend the FMLA’s protection to next of kin and to adult children. The Department of Labour on 22 June 2010 clarified the definition of “son and daughter” under the FMLA “to ensure that an employee who assumes the role of caring for a child receives parental rights to family leave regardless of the legal or biological relationship” and specifying that “an employee who intends to share in the parenting of a child with their same sex partner will be able to exercise the right to FMLA leave to bond with that child.”

In February 2015, the Department of Labour issued its final rule amending the definition of spouse under the FMLA in response to the decision in United States v. Windsor, effective 27 March 2015. The revised definition of “spouse” extends FMLA leave rights and job protections to eligible employees in a same-sex marriage or a common-law marriage entered into in a state where those statuses are legally recognised, regardless of the state in which the employee works or resides. Even if an employee works where same-sex or common law marriage is not recognized, that employee’s spouse triggers FMLA coverage if the employee married in a state that recognized same-sex marriage or common law marriage. Some states had already expanded the definition of family in their own FMLAs:

  • California: Domestic partner and domestic partner’s child.
  • Connecticut: Civil union partner, parent-in-law.
  • Hawaii: Grandparent, parent-in-law, grandparent-in-law or an employee’s reciprocal beneficiary.
  • Maine: Domestic partner and domestic partner’s child, siblings.
  • Maryland: Allows the employee to use time for immediate family under the same rules if taking it for themselves. Includes step, adopted and even people who were primary caregivers even if not related.
  • New Jersey: Civil union partner and child of civil union partner, parent-in-law, step parent.
  • Oregon: Domestic partner, grandparent, grandchild or parent-in-law.
  • Rhode Island: Domestic partners of state employees, parent-in-law.
  • Vermont: Civil union partner, parent-in-law.
  • Wisconsin: Parent-in-law.
  • District of Columbia: Related to the worker by blood, legal custody, or marriage; person with whom the employee lives and has a committed relationship; child who lives with employee and for whom employee permanently assumes and discharges parental responsibility.

Increasing the Uses for FMLA Leave

FMLA leave can be used for a worker’s serious health condition, the serious health condition of a family member, or upon the arrival of a new child. State FMLA laws and the new military family provisions of the FMLA have broadened these categories:

  • Connecticut: Organ or bone marrow donor.
  • Maine: Organ donor; death of employee’s family member if that family member is a servicemember killed while on active duty.
  • Maryland: Maryland Family Leave Act (MFLA) – Organ donor, Person Standing in Loco Parentis, For Service Leave, and added a specific anti-retaliation penalty on top of FMLA recovery. Runs parallel to FMLA.
  • Oregon: Care for the non-serious injury or illness of a child requiring home care.

Unpaid Leave for Other Related Purposes

Several states have passed FMLA-type statutes to give parents unpaid leave for other related purposes, including:

  • Attending child’s school or educational activities. Examples include California, District of Columbia, Massachusetts, Minnesota, Rhode Island, Vermont, and others.
  • Taking family members to routine medical visits. Massachusetts and Vermont.
  • Addressing the effects of domestic violence, stalking, or sexual assault. Examples include Colorado, Florida, Hawaii, and Illinois.

Significance

In 2003, Han and Waldfogel found that “only about 60% of private sector workers are covered” due to the clause stipulating a minimum number of employees, and once the clause stipulating a minimum number of hours worked is added, only 46% of private sector workers are eligible for leave under the FMLA. In June 2007, the Department of Labour estimated that of 141.7 million workers in the United States, 94.4 million worked at FMLA-covered worksites, and 76.1 million were eligible for FMLA leave. Only eight to 17.1% of covered, eligible workers (or between 6.1 million and 13.0 million workers) took FMLA leave in 2005. The 2008 National Survey of Employers found no statistically significant difference between the proportion of small employers (79%) and large employers (82%) that offer full FMLA coverage.

Although much of the research has been conducted on populations in other countries, Berger and colleagues found that children in the United States whose mothers return to work within the first 3 months after giving birth are less likely to be breastfed, have all of their immunisations up to date (by 18 months), and receive all of their regular medical checkups; they are also more likely to exhibit behavioural problems by four years of age. Chatterji and Markowitz also found an association between longer lengths of maternity leave and lesser incidence of depression among mothers.

Despite the lack of rights to leave, there is no right to free child care or day care. This has encouraged several proposals to create a public system of free child care, or for the government to subsidise parents’ costs.

Controversy

The act was controversial at its passage. Much of the controversy focused on its impact on the business community, and on whether the law should be gender neutral or not. In order to make the law more acceptable, it was argued that the law would reduce abortions. Proponents of the law focused on its benefit to men and children, in order to counter the claim that it was giving women “special treatment”. Other controversies focused on whether the leave should be paid or not.

The law was finally approved, mandating unpaid gender-neutral leave; nevertheless it was still criticised. Critics of the act have suggested that by mandating various forms of leave that are used more often by female than male employees, the Act, like the Pregnancy Discrimination Act of 1978, makes women more expensive to employ than men. They argue that employers will engage in subtle discrimination against women in the hiring process, discrimination which is much less obvious to detect than pregnancy discrimination against the already hired. Throughout history, gender discrimination towards women was common; certain laws were placed that would restrict a woman’s option in choosing a working position, as well as, how many hours she could work, i.e. Employers Supporters counter that the act, in contrast to the Pregnancy Discrimination Act of 1978, is aimed at both women and men, and is part of an overall strategy to encourage both men and women to take family-related leave. However, this is based on the assumption that men will take advantage of the opportunity of unpaid leave at comparable rates to women. According to Grossman, there is no basis for this assumption upon the inception of the legislation and no evidence has been found today to support this assumption. Therefore, the employer incentive to prefer male employees is preserved despite the equal opportunity for both sexes to take leave.

Moreover, the FMLA is much less comprehensive than Western European leave policies. Namely, the United States is the only industrialised country without paid leave for parents. This illustrates the lack of provisions offered in the United States as compared to that of other industrialised countries. For instance, all Western European nations have maternity paid leave and over half have paternity and sick child care paid leave, while the United States has no paid leave.

Additionally, workplace fairness has been questioned under the Act. For instance, any woman-specific benefits provided by the legislation were considered special treatment and thus unacceptable, and ignoring the idea that women may have a greater share of burden of caregiving in reality. In retort, supporters may argue that creating such legislation that recognises the female’s greater role in child care, stereotype would be reinforced.

The success of the implementation of the policy is also controversial because it is questioned whether the policy is actually going to those who need the benefits. For instance, since the leave offered is unpaid, majorities of eligible employees can not take time off because they can not afford to do so. And according to Pyle and Pelletier, eligible workers may not even know about this policy and the benefits allotted to them.

Under law, women are protected from sex discrimination in the workplace but a large stigma against women still exists in terms of them being equally skilled as their male co-workers, and ultimately testing the federal protection of rights in a work environment. Like any other federal regulation, it is strictly prohibited for an employer to discriminate towards an employee (especially if the employee is using their FMLA rights), and to strain from providing accurate information for all employees to access.

Signing Ceremony

Vicki Yandle, a receptionist who was fired after asking for a few weeks of time off to care for a daughter with cancer, was on stage with President Clinton when the law was signed.

On This Day … 01 September

Published on by Andrew MarshallLeave a comment

Events

  • 1939 – Adolf Hitler signs an order to begin the systematic euthanasia of mentally ill and disabled people.

People (Births)

  • 1848 – Auguste Forel, Swiss myrmecologist, neuroanatomist, and psychiatrist (d. 1931).
  • 1902 – Kazimierz Dąbrowski, Polish psychiatrist and psychologist (d. 1980).
  • 1950 – Phil McGraw, American psychologist, author, and talk show host.

Auguste Forel

Auguste-Henri Forel (01 September 1848 to 27 July 1931) was a Swiss myrmecologist, neuroanatomist, psychiatrist and eugenicist, notable for his investigations into the structure of the human brain and that of ants. For example, he is considered a co-founder of the neuron theory.

Forel is also known for his early contributions to sexology and psychology. From 1978 until 2000 Forel’s image appeared on the 1000 Swiss franc banknote.

Kazimierz Dabrowski

Kazimierz Dąbrowski (01 September 1902 to 26 November 1980) was a Polish psychologist, psychiatrist, and physician.

He is best known for his theory of “positive disintegration” as a mechanism in personality development. He was also a poet who used the pen name “Paul Cienin, Paweł Cienin”.

Phil McGraw

Phillip Calvin McGraw (born 01 September 1950), better known as Dr. Phil, is an American television personality, author and the host of the television show Dr. Phil. He holds a doctorate in Clinical psychology, though he ceased renewing his license to practice Psychology in 2006.

McGraw rose to fame with appearances on The Oprah Winfrey Show in the late 1990s. Oprah Winfrey then helped McGraw launch his own programme, Dr. Phil, in September 2002. The show is formatted as an advice show.

What is the Americans with Disabilities Act of 1990?

Published on by Andrew Marshall4 Comments

Introduction

The Americans with Disabilities Act of 1990 or ADA (42 U.S.C. § 12101) is a civil rights law that prohibits discrimination based on disability.

It affords similar protections against discrimination to Americans with disabilities as the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin, and other characteristics illegal, and later sexual orientation. In addition, unlike the Civil Rights Act, the ADA also requires covered employers to provide reasonable accommodations to employees with disabilities, and imposes accessibility requirements on public accommodations.

In 1986, the National Council on Disability had recommended the enactment of an Americans with Disabilities Act (ADA) and drafted the first version of the bill which was introduced in the House and Senate in 1988. The final version of the bill was signed into law on 26 July 1990, by President George H. W. Bush. It was later amended in 2008 and signed by President George W. Bush with changes effective as of 01 January 2009.

Brief History

The ADA has roots in Section 504 of the Rehabilitation Act of 1973.

Drafting

In 1986, the National Council on Disability (NCD), an independent federal agency, issued a report, Towards Independence, in which the Council examined incentives and disincentives in federal laws towards increasing the independence and full integration of people with disabilities into our society. Among the disincentives to independence the Council identified was the existence of large remaining gaps in our nation’s civil rights coverage for people with disabilities. A principal conclusion of the report was to recommend the adoption of comprehensive civil rights legislation, which became the ADA.

The idea of federal legislation enhancing and extending civil rights legislation to millions of Americans with disabilities gained bipartisan support in late 1988 and early 1989. In early 1989 both Congress and the newly inaugurated Bush White House worked separately, then jointly, to write legislation capable of expanding civil rights without imposing undue harm or costs on those already in compliance with existing rules and laws.

Lobbying

Over the years, key activists and advocates played an important role in lobbying members of the US Congress to develop and pass the ADA, including Justin Whitlock Dart Jr., Patrisha Wright and others.

Ms. Wright is known as “the General” for her work in coordinating the campaign to enact the ADA. She is widely considered the main force behind the campaign lobbying for the ADA.

Support and Opposition

Support

About the importance of making employment opportunities inclusive, Shirley Davis, director of global diversity and inclusion at the Society for Human Resource Management, said: “People with disabilities represent a critical talent pool that is underserved and underutilized”.

Opposition from Religious Groups

The debate over the ADA led some religious groups to take opposite positions. The Association of Christian Schools International opposed the ADA in its original form, primarily because the ADA labelled religious institutions “public accommodations” and thus would have required churches to make costly structural changes to ensure access for all. The cost argument advanced by ACSI and others prevailed in keeping religious institutions from being labelled as “public accommodations”.

Church groups such as the National Association of Evangelicals testified against the ADA’s Title I employment provisions on grounds of religious liberty. The NAE believed the regulation of the internal employment of churches was “… an improper intrusion [of] the federal government.”

Opposition from Business Interests

Many members of the business community opposed the Americans with Disabilities Act. Testifying before Congress, Greyhound Bus Lines stated that the act had the potential to “deprive millions of people of affordable intercity public transportation and thousands of rural communities of their only link to the outside world.” The US Chamber of Commerce argued that the costs of the ADA would be “enormous” and have “a disastrous impact on many small businesses struggling to survive.” The National Federation of Independent Businesses, an organization that lobbies for small businesses, called the ADA “a disaster for small business.” Pro-business conservative commentators joined in opposition, writing that the Americans with Disabilities Act was “an expensive headache to millions” that would not necessarily improve the lives of people with disabilities.

“Capitol Crawl”

Shortly before the act was passed, disability rights activists with physical disabilities coalesced in front of the Capitol Building, shed their crutches, wheelchairs, powerchairs and other assistive devices, and immediately proceeded to crawl and pull their bodies up all 100 of the Capitol’s front steps, without warning. As the activists did so, many of them chanted “ADA now”, and “Vote, Now”. Some activists who remained at the bottom of the steps held signs and yelled words of encouragement at the “Capitol Crawlers”. Jennifer Keelan, a second grader with cerebral palsy, was videotaped as she pulled herself up the steps, using mostly her hands and arms, saying “I’ll take all night if I have to.” This direct action is reported to have “inconvenienced” several senators and to have pushed them to approve the act. While there are those who do not attribute much overall importance to this action, the “Capitol Crawl” of 1990 is seen by some present-day disability activists in the United States as a central act for encouraging the ADA into law.

Final Passage

Senator Tom Harkin (D-IA) authored what became the final bill and was its chief sponsor in the Senate. Harkin delivered part of his introduction speech in sign language, saying it was so his deaf brother could understand.

George H. W. Bush, on signing the measure on 26 July 1990, said:

I know there may have been concerns that the ADA may be too vague or too costly, or may lead endlessly to litigation. But I want to reassure you right now that my administration and the United States Congress have carefully crafted this Act. We’ve all been determined to ensure that it gives flexibility, particularly in terms of the timetable of implementation; and we’ve been committed to containing the costs that may be incurred…. Let the shameful wall of exclusion finally come tumbling down.

ADA Amendments Act (2008)

The ADA defines a covered disability as a physical or mental impairment that substantially limits one or more major life activities, a history of having such an impairment, or being regarded as having such an impairment. The Equal Employment Opportunity Commission (EEOC) was charged with interpreting the 1990 law with regard to discrimination in employment. The EEOC developed regulations limiting an individual’s impairment to one that “severely or significantly restricts” a major life activity. The ADAAA directed the EEOC to amend its regulations and replace “severely or significantly” with “substantially limits”, a more lenient standard.

On 25 September 2008, President George W. Bush signed the ADA Amendments Act of 2008 (ADAAA) into law. The amendment broadened the definition of “disability”, thereby extending the ADA’s protections to a greater number of people. The ADAAA also added to the ADA examples of “major life activities” including, but not limited to, “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working” as well as the operation of several specified major bodily functions. The act overturned a 1999 US Supreme Court case that held that an employee was not disabled if the impairment could be corrected by mitigating measures; it specifically provides that such impairment must be determined without considering such ameliorative measures. It also overturned the court restriction that an impairment that substantially limits one major life activity must also limit others to be considered a disability. In 2008, the United States House Committee on Education and Labour stated that the amendment “makes it absolutely clear that the ADA is intended to provide broad coverage to protect anyone who faces discrimination on the basis of disability.” Thus the ADAAA led to broader coverage of impaired employees.

25th Anniversary (2015)

As of 2015 the ADA had improved access to public services, the built environment (e.g. crosswalks with curb cuts and accessible pedestrian signals), understanding of the abilities of people with disabilities, established a right to equal access to public services and has demonstrated the contributions which people with disabilities can make to the economy. Disparities have remained in employment, earned income, Internet access, transportation, housing, and educational attainment and the disabled remain at a disadvantage with respect to health and health care.

On 20 July 2015, the White House held a reception to celebrate the 25th anniversary of the ADA. The introductory remarks were given by Haben Girma, a deafblind disability rights lawyer and advocate. Among the guests was Alice Wong, a disability rights activist who came via telepresence robot.

Web Content Accessibility Guidelines (2019)

In October 2019, the Supreme Court declined to resolve a circuit split as to whether websites are covered by the ADA. The Court turned down an appeal from Domino’s Pizza and let stand a US 9th Circuit Court of Appeals ruling which held that the Americans With Disabilities Act protects access not just to brick-and-mortar public accommodations, but also to the websites and apps of those businesses.

Disabilities Included

ADA disabilities include both mental and physical medical conditions. A condition does not need to be severe or permanent to be a disability.

Equal Employment Opportunity Commission regulations provide a list of conditions that should easily be concluded to be disabilities: deafness, blindness, an intellectual disability (formerly termed mental retardation), partially or completely missing limbs or mobility impairments requiring the use of a wheelchair, autism, cancer, cerebral palsy, diabetes, epilepsy, attention deficit hyperactivity disorder, Human Immunodeficiency Virus (HIV) infection, multiple sclerosis, muscular dystrophy, major depressive disorder, bipolar disorder, post-traumatic stress disorder, obsessive compulsive disorder, and schizophrenia. Other mental or physical health conditions also may be disabilities, depending on what the individual’s symptoms would be in the absence of “mitigating measures” (medication, therapy, assistive devices, or other means of restoring function), during an “active episode” of the condition (if the condition is episodic).

Certain specific conditions that are widely considered anti-social, or tend to result in illegal activity, such as kleptomania, paedophilia, exhibitionism, voyeurism, etc. are excluded under the definition of “disability” in order to prevent abuse of the statute’s purpose. Additionally, gender identity or orientation is no longer considered a disorder and is also excluded under the definition of “disability”.

Titles

Title I – Employment

The ADA states that a “covered entity” shall not discriminate against “a qualified individual with a disability”. This applies to job application procedures, hiring, advancement and discharge of employees, job training, and other terms, conditions, and privileges of employment. “Covered entities” include employers with 15 or more employees, as well as employment agencies, labour organisations, and joint labour-management committees. There are strict limitations on when a covered entity can ask job applicants or employees disability-related questions or require them to undergo medical examination, and all medical information must be kept confidential.

Prohibited discrimination may include, among other things, firing or refusing to hire someone based on a real or perceived disability, segregation, and harassment based on a disability. Covered entities are also required to provide reasonable accommodations to job applicants and employees with disabilities. A reasonable accommodation is a change in the way things are typically done that the person needs because of a disability, and can include, among other things, special equipment that allows the person to perform the job, scheduling changes, and changes to the way work assignments are chosen or communicated. An employer is not required to provide an accommodation that would involve undue hardship (significant difficulty or expense), and the individual who receives the accommodation must still perform the essential functions of the job and meet the normal performance requirements. An employee or applicant who currently engages in the illegal use of drugs is not considered qualified when a covered entity takes adverse action based on such use.

There are many ways to discriminate against people based on disabilities, including psychological ones. Anyone known to have a history of mental disorders can be considered disabled. Employers with more than 15 employees must take care to treat all employees fairly and with any accommodations needed. Even when an employee is doing a job exceptionally well, she or he is not necessarily no longer disabled; employers must continue to follow all policies for the disabled.

Part of Title I was found unconstitutional by the United States Supreme Court as it pertains to states in the case of Board of Trustees of the University of Alabama v. Garrett as violating the sovereign immunity rights of the several states as specified by the Eleventh Amendment to the United States Constitution. The Court determined that state employees cannot sue their employer for violating ADA rules. State employees can, however, file complaints at the Department of Justice or the Equal Employment Opportunity Commission, who can sue on their behalf.

Title II – Public Entities (and Public Transportation)

Title II prohibits disability discrimination by all public entities at the local level, e.g., school district, municipal, city, or county, and at state level. Public entities must comply with Title II regulations by the US Department of Justice. These regulations cover access to all programmes and services offered by the entity. Access includes physical access described in the ADA Standards for Accessible Design and programmatic access that might be obstructed by discriminatory policies or procedures of the entity.

Title II applies to public transportation provided by public entities through regulations by the US Department of Transportation. It includes the National Railroad Passenger Corporation (Amtrak), along with all other commuter authorities. This section requires the provision of paratransit services by public entities that provide fixed-route services. ADA also sets minimum requirements for space layout in order to facilitate wheelchair securement on public transport.

Title II also applies to all state and local public housing, housing assistance, and housing referrals. The Office of Fair Housing and Equal Opportunity is charged with enforcing this provision.

Title III – Public Accommodations (and Commercial Facilities)

Under Title III, no individual may be discriminated against on the basis of disability with regards to the full and equal enjoyment of the goods, services, facilities, or accommodations of any place of public accommodation by any person who owns, leases, or operates a place of public accommodation. Public accommodations include most places of lodging (such as inns and hotels), recreation, transportation, education, and dining, along with stores, care providers, and places of public displays.

Under Title III of the ADA, all new construction (construction, modification or alterations) after the effective date of the ADA (approximately July 1992) must be fully compliant with the Americans With Disabilities Act Accessibility Guidelines (ADAAG) found in the Code of Federal Regulations at 28 C.F.R., Part 36, Appendix A.

Title III also has applications to existing facilities. One of the definitions of “discrimination” under Title III of the ADA is a “failure to remove” architectural barriers in existing facilities. See 42 U.S.C. § 12182(b)(2)(A)(iv). This means that even facilities that have not been modified or altered in any way after the ADA was passed still have obligations. The standard is whether “removing barriers” (typically defined as bringing a condition into compliance with the ADAAG) is “readily achievable”, defined as “…easily accomplished without much difficulty or expense”.

The statutory definition of “readily achievable” calls for a balancing test between the cost of the proposed “fix” and the wherewithal of the business and/or owners of the business. Thus, what might be “readily achievable” for a sophisticated and financially capable corporation might not be readily achievable for a small or local business.

There are exceptions to this title; many private clubs and religious organizations may not be bound by Title III. With regard to historic properties (those properties that are listed or that are eligible for listing in the National Register of Historic Places, or properties designated as historic under state or local law), those facilities must still comply with the provisions of Title III of the ADA to the “maximum extent feasible” but if following the usual standards would “threaten to destroy the historic significance of a feature of the building” then alternative standards may be used.

Under 2010 revisions of Department of Justice regulations, newly constructed or altered swimming pools, wading pools, and spas must have an accessible means of entrance and exit to pools for disabled people. However, the requirement is conditioned on whether providing access through a fixed lift is “readily achievable”. Other requirements exist, based on pool size, include providing a certain number of accessible means of entry and exit, which are outlined in Section 242 of the standards. However, businesses are free to consider the differences in the application of the rules depending on whether the pool is new or altered, or whether the swimming pool was in existence before the effective date of the new rule. Full compliance may not be required for existing facilities; Section 242 and 1009 of the 2010 Standards outline such exceptions.

Service Animals

The ADA provides explicit coverage for service animals. Guidelines have been developed not only to protect persons with disabilities but also to indemnify businesses from damages related to granting access to service animals on their premises. Businesses are allowed to ask if the animal is a service animal and ask what tasks it is trained to perform, but they are not allowed to ask the service animal to perform the task nor ask for a special ID of the animal. They cannot ask what the person’s disabilities are. A person with a disability cannot be removed from the premises unless either of two things happen: the animal is out of control and its owner cannot get it under control (e.g. a dog barking uncontrollably in a restaurant), or the animal is a direct threat to people’s health and safety. Allergies and fear of animals would not be considered a threat to people’s health and safety, so it would not be a valid reason to deny access to people with service animals. Businesses that prepare or serve food must allow service animals and their owners on the premises even if state or local health laws otherwise prohibit animals on the premises. In this case, businesses that prepare or serve food are not required to provide care or food for service animals, nor do they have to provide a designated area for the service animal to relieve itself. Lastly, people that require service dogs cannot be charged an extra fee for their service dog or be treated unfairly, for example, being isolated from people at a restaurant. People with disabilities cannot be treated as “less than” other customers. However, if a business normally charges for damages caused by the person to property, the customer with a disability will be charged for his/her service animal’s damages to the property.

Auxiliary Aids

The ADA provides explicit coverage for auxiliary aids.

Auxiliary aids and services are items, equipment or services that assist in effective communication between a person who has a hearing, vision or speech disability and a person who does not.

ADA says that a public accommodation shall take those steps that may be necessary to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services, unless the public accommodation can demonstrate that taking those steps would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered or would result in an undue burden, i.e. significant difficulty or expense. The term “auxiliary aids and services” includes:

  • Qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing;
  • Qualified readers; taped texts; audio recordings; Brailled materials and displays; screen reader software; magnification software; optical readers; secondary auditory programmes (SAP); large print materials; accessible electronic and information technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision;
  • Acquisition or modification of equipment or devices; and
  • Other similar services and actions.

Captions are considered one type of auxiliary aid. Since the passage of the ADA, the use of captioning has expanded. Entertainment, educational, informational, and training materials are captioned for deaf and hard-of-hearing audiences at the time they are produced and distributed. The Television Decoder Circuitry Act of 1990 requires that all televisions larger than 13 inches sold in the United States after July 1993 have a special built-in decoder that enables viewers to watch closed-captioned programming. The Telecommunications Act of 1996 directs the Federal Communications Commission (FCC) to adopt rules requiring closed captioning of most television programming. The FCC’s rules on closed captioning became effective 01 January 1998.

Title IV – Telecommunications

Title IV of the ADA amended the landmark Communications Act of 1934 primarily by adding section 47 U.S.C. § 225. This section requires that all telecommunications companies in the U.S. take steps to ensure functionally equivalent services for consumers with disabilities, notably those who are deaf or hard of hearing and those with speech impairments. When Title IV took effect in the early 1990s, it led to the installation of public teletypewriter (TTY) machines and other TDD (telecommunications devices for the deaf). Title IV also led to the creation, in all 50 states and the District of Columbia, of what was then called dual-party relay services and now are known as Telecommunications Relay Services (TRS), such as STS relay. Today, many TRS-mediated calls are made over the Internet by consumers who use broadband connections. Some are Video Relay Service (VRS) calls, while others are text calls. In either variation, communication assistants translate between the signed or typed words of a consumer and the spoken words of others. In 2006, according to the Federal Communications Commission (FCC), VRS calls averaged two million minutes a month.

Title V – Miscellaneous Provisions

Title V includes technical provisions. It discusses, for example, the fact that nothing in the ADA amends, overrides or cancels anything in Section 504. Additionally, Title V includes an anti-retaliation or coercion provision. The Technical Assistance Manual for the ADA explains this provision:

III-3.6000 Retaliation or coercion. Individuals who exercise their rights under the ADA, or assist others in exercising their rights, are protected from retaliation. The prohibition against retaliation or coercion applies broadly to any individual or entity that seeks to prevent an individual from exercising his or her rights or to retaliate against him or her for having exercised those rights … Any form of retaliation or coercion, including threats, intimidation, or interference, is prohibited if it is intended to interfere.

Reaction

Criticism

Employment

The ADA has been criticised on the grounds that it decreases the employment rate for people with disabilities and raises the cost of doing business for employers, in large part due to the additional legal risks, which employers avoid by quietly avoiding hiring people with disabilities. Some researchers believe that the law has been ineffectual. Between 1991 (after the enactment of the ADA) and 1995, the employment rate of men with disabilities dropped by 7.8% regardless of age, educational level, or type of disability, with the most affected being young, less-educated and mentally disabled men. Despite the many criticisms, a causal link between the ADA and declining disabled employment over much of the 1990s has not been definitively identified.

In 2001, for men of all working ages and women under 40, Current Population Survey data showed a sharp drop in the employment of disabled workers, leading at least two economists to attribute the cause to the Act. By contrast, a study in 2003 found that while the Act may have led to short term reactions by employers, in the long term, there were either positive or neutral consequences for wages and employment. In 2005 the rate of employment among disabled people increased to 45% of the population of disabled people.

“Professional Plaintiffs”

Since enforcement of the act began in July 1992, it has quickly become a major component of employment law. The ADA allows private plaintiffs to receive only injunctive relief (a court order requiring the public accommodation to remedy violations of the accessibility regulations) and attorneys’ fees, and does not provide monetary rewards to private plaintiffs who sue non-compliant businesses. Unless a state law, such as the California Unruh Civil Rights Act, provides for monetary damages to private plaintiffs, persons with disabilities do not obtain direct financial benefits from suing businesses that violate the ADA.

The attorneys’ fees provision of Title III does provide incentive for lawyers to specialise and engage in serial ADA litigation, but a disabled plaintiff does not obtain a financial reward from attorneys’ fees unless they act as their own attorney, or as mentioned above, a disabled plaintiff resides in a state that provides for minimum compensation and court fees in lawsuits. Moreover, there may be a benefit to these “private attorneys general” who identify and compel the correction of illegal conditions: they may increase the number of public accommodations accessible to persons with disabilities. “Civil rights law depends heavily on private enforcement. Moreover, the inclusion of penalties and damages is the driving force that facilitates voluntary compliance with the ADA.” Courts have noted:

As a result, most ADA suits are brought by a small number of private plaintiffs who view themselves as champions of the disabled. For the ADA to yield its promise of equal access for the disabled, it may indeed be necessary and desirable for committed individuals to bring serial litigation advancing the time when public accommodations will be compliant with the ADA.

However, in states that have enacted laws that allow private individuals to win monetary awards from non-compliant businesses (as of 2008, these include California, Florida, Hawaii, and Illinois), “professional plaintiffs” are typically found. At least one of these plaintiffs in California has been barred by courts from filing lawsuits unless he receives prior court permission. Through the end of fiscal year 1998, 86% of the 106,988 ADA charges filed with and resolved by the Equal Employment Opportunity Commission, were either dropped or investigated and dismissed by EEOC but not without imposing opportunity costs and legal fees on employers.

Case Law

There have been some notable cases regarding the ADA. For example, two major hotel room marketers (Expedia.com and Hotels.com) with their business presence on the Internet were sued because its customers with disabilities could not reserve hotel rooms through their websites without substantial extra efforts that persons without disabilities were not required to perform. These represent a major potential expansion of the ADA in that this, and other similar suits (known as “bricks vs. clicks”), seeks to expand the ADA’s authority to cyberspace, where entities may not have actual physical facilities that are required to comply.

Green v. State of California

Green v. State of California, No. S137770 (Cal. Aug. 23, 2007) was a case in which the majority of the Supreme Court in California was faced with deciding whether the employee suing the state is required to prove he is able to perform “essential” job duties, regardless of whether or not there was “reasonable accommodation,” or if the employer must prove the victim was unable to do so. The court ruled the burden was on the employee, not the employer, and reversed a disputed decision by the courts. Plaintiff attorney David Greenberg brought forth considerations of the concept that, even in the state of California, employers do not have to employ a worker who is unable to perform “essential job functions” with “reasonable accommodation.” Forcing employers to do so “would defy logic and establish a poor public policy in employment matters.”

National Federation of the Blind v. Target Corporation

National Federation of the Blind v. Target Corporation was a case where a major retailer, Target Corp., was sued because their web designers failed to design its website to enable persons with low or no vision to use it.

Board of Trustees of the University of Alabama v. Garrett

Board of Trustees of the University of Alabama v. Garrett was a United States Supreme Court case about Congress’s enforcement powers under the Fourteenth Amendment to the Constitution. It decided that Title I of the Americans with Disabilities Act was unconstitutional insofar as it allowed private citizens to sue states for money damages.

Barden v. The City of Sacramento

Barden v. The City of Sacramento, filed in March 1999, claimed that the City of Sacramento failed to comply with the ADA when, while making public street improvements, it did not bring its sidewalks into compliance with the ADA. Certain issues were resolved in Federal Court. One issue, whether sidewalks were covered by the ADA, was appealed to the 9th Circuit Court of Appeals, which ruled that sidewalks were a “program” under ADA and must be made accessible to persons with disabilities. The ruling was later appealed to the US Supreme Court, which refused to hear the case, letting stand the ruling of the 9th Circuit Court.

Bates v. UPS

Bates v. UPS (begun in 1999) was the first equal opportunity employment class action brought on behalf of Deaf and Hard of Hearing (d/Deaf/HoH) workers throughout the country concerning workplace discrimination. It established legal precedence for d/Deaf/HoH Employees and Customers to be fully covered under the ADA. Key findings included:

  • UPS failed to address communication barriers and to ensure equal conditions and opportunities for deaf employees;
  • Deaf employees were routinely excluded from workplace information, denied opportunities for promotion, and exposed to unsafe conditions due to lack of accommodations by UPS;
  • UPS also lacked a system to alert these employees as to emergencies, such as fires or chemical spills, to ensure that they would safely evacuate their facility; and
  • UPS had no policy to ensure that deaf applicants and employees actually received effective communication in the workplace.

The outcome was that UPS agreed to pay a $5.8 million award and agreed to a comprehensive accommodations programme that was implemented in their facilities throughout the country.

Spector v. Norwegian Cruise Line Ltd

Spector v. Norwegian Cruise Line Ltd was a case that was decided by the United States Supreme Court in 2005. The defendant argued that as a vessel flying the flag of a foreign nation it was exempt from the requirements of the ADA. This argument was accepted by a federal court in Florida and, subsequently, the Fifth Circuit Court of Appeals. However, the US Supreme Court reversed the ruling of the lower courts on the basis that Norwegian Cruise Lines was a business headquartered in the United States whose clients were predominantly Americans and, more importantly, operated out of port facilities throughout the United States.

Olmstead v. L.C.

Not to be confused with Olmstead v. United States, 277 U.S. 438 (1928), a case regarding wiretapping.

Olmstead v. L.C. was a case before the United States Supreme Court in 1999. The two plaintiffs, L.C. and E.W., were institutionalised in Georgia for diagnosed mental retardation and schizophrenia. Clinical assessments by the state determined that the plaintiffs could be appropriately treated in a community setting rather than the state institution. The plaintiffs sued the state of Georgia and the institution for being inappropriately treated and housed in the institutional setting rather than being treated in one of the state’s community-based treatment facilities.

The Supreme Court decided under Title II of the ADA that mental illness is a form of disability and therefore covered under the ADA, and that unjustified institutional isolation of a person with a disability is a form of discrimination because it “…perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.” The court added, “Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.”

Therefore, under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programmes or activities of any public entity.

Michigan Paralysed Veterans of America v. The University of Michigan

This was a case filed before The United States District Court for the Eastern District of Michigan Southern Division on behalf of the Michigan Paralysed Veterans of America against University of Michigan – Michigan Stadium claiming that Michigan Stadium violated the Americans with Disabilities Act in its $226-million renovation by failing to add enough seats for disabled fans or accommodate the needs for disabled restrooms, concessions and parking. Additionally, the distribution of the accessible seating was at issue, with nearly all the seats being provided in the end-zone areas. The US Department of Justice assisted in the suit filed by attorney Richard Bernstein of The Law Offices of Sam Bernstein in Farmington Hills, Michigan, which was settled in March 2008. The settlement required the stadium to add 329 wheelchair seats throughout the stadium by 2010, and an additional 135 accessible seats in clubhouses to go along with the existing 88 wheelchair seats. This case was significant because it set a precedent for the uniform distribution of accessible seating and gave the DOJ the opportunity to clarify previously unclear rules. The agreement now is a blueprint for all stadiums and other public facilities regarding accessibility.

Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers

One of the first major ADA lawsuits, Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers (PVA 1996) was focused on the wheelchair accessibility of a stadium project that was still in the design phase, MCI Centre (now known as Capital One Arena) in Washington, D.C. Previous to this case, which was filed only five years after the ADA was passed, the DOJ was unable or unwilling to provide clarification on the distribution requirements for accessible wheelchair locations in large assembly spaces. While Section 4.33.3 of ADAAG makes reference to lines of sight, no specific reference is made to seeing over standing patrons. The MCI Centre, designed by Ellerbe Becket Architects & Engineers, was designed with too few wheelchair and companion seats, and the ones that were included did not provide sight lines that would enable the wheelchair user to view the playing area while the spectators in front of them were standing. This case and another related case established precedent on seat distribution and sight lines issues for ADA enforcement that continues to present day.

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams, was a case in which the Supreme Court interpreted the meaning of the phrase “substantially impairs” as used in the Americans with Disabilities Act. It reversed a Sixth Court of Appeals decision to grant a partial summary judgement in favour of the respondent, Ella Williams, that qualified her inability to perform manual job-related tasks as a disability. The Court held that the “major life activity” definition in evaluating the performance of manual tasks focuses the inquiry on whether Williams was unable to perform a range of tasks central to most people in carrying out the activities of daily living. The issue is not whether Williams was unable to perform her specific job tasks. Therefore, the determination of whether an impairment rises to the level of a disability is not limited to activities in the workplace solely, but rather to manual tasks in life in general. When the Supreme Court applied this standard, it found that the Court of Appeals had incorrectly determined the presence of a disability because it relied solely on her inability to perform specific manual work tasks, which was insufficient in proving the presence of a disability. The Court of Appeals should have taken into account the evidence presented that Williams retained the ability to do personal tasks and household chores, such activities being the nature of tasks most people do in their daily lives, and placed too much emphasis on her job disability. Since the evidence showed that Williams was performing normal daily tasks, it ruled that the Court of Appeals erred when it found that Williams was disabled. This ruling is now, however, no longer good law – it was invalidated by the ADAAA. In fact, Congress explicitly cited Toyota v. Williams in the text of the ADAAA itself as one of its driving influences for passing the ADAAA.

US Airways, Inc. v. Barnett

Decided by the US Supreme Court in 2002, this case held that even requests for accommodation that might seem reasonable on their face, e.g. a transfer to a different position, can be rendered unreasonable because it would require a violation of the company’s seniority system. While the court held that, in general, a violation of a seniority system renders an otherwise reasonable accommodation unreasonable, a plaintiff can present evidence that, despite the seniority system, the accommodation is reasonable in the specific case at hand, e.g. the plaintiff could offer evidence that the seniority system is so often disregarded that another exception would not make a difference.

Importantly, the court held that the defendant need not provide proof that this particular application of the seniority system should prevail, and that, once the defendant showed that the accommodation violated the seniority system, it fell to Barnett to show it was nevertheless reasonable.

In this case, Barnett was a US Airways employee who injured his back, rendering him physically unable to perform his cargo-handling job. Invoking seniority, he transferred to a less-demanding mailroom job, but this position later became open to seniority-based bidding and was bid on by more senior employees. Barnett requested the accommodation of being allowed to stay on in the less-demanding mailroom job. US Airways denied his request, and he lost his job.

The Supreme Court decision invalidated both the approach of the district court, which found that the mere presence and importance of the seniority system was enough to warrant a summary judgment in favour of US Airways, as well as the circuit court’s approach that interpreted ‘reasonable accommodation’ as ‘effective accommodation.’

Access Now v. Southwest Airlines

Access Now v. Southwest Airlines was a case where the District Court decided that the website of Southwest Airlines was not in violation of the Americans with Disabilities Act, because the ADA is concerned with things with a physical existence and thus cannot be applied to cyberspace. Judge Patricia A. Seitz found that the “virtual ticket counter” of the website was a virtual construct, and hence not a “public place of accommodation.” As such, “To expand the ADA to cover ‘virtual’ spaces would be to create new rights without well-defined standards.

Ouellette v. Viacom International Inc.

Ouellette v. Viacom International Inc. followed in Access Now’s footsteps by holding that a mere online presence does not subject a website to the ADA guidelines. Thus Myspace and YouTube were not liable for a dyslexic man’s inability to navigate the site regardless of how impressive the “online theatre” is.

Authors Guild v. HathiTrust

Authors Guild v. HathiTrust was a case in which the District Court decided that the HathiTrust digital library was a transformative, fair use of copyrighted works, making a large number of written text available to those with print disability.

Zamora-Quezada v. HealthTexas Medical Group

Zamora-Quezada v. HealthTexas Medical Group (begun in 1998) was the first time this act was used against HMOs when a novel lawsuit was filed by Texas attorney Robert Provan against five HMOs for their practice of revoking the contracts of doctors treating disabled patients.

Campbell v. General Dynamics Government Systems Corp.

Campbell v. General Dynamics Government Systems Corp. (2005) concerned the enforceability of a mandatory arbitration agreement, contained in a dispute resolution policy linked to an e-mailed company-wide announcement, insofar as it applies to employment discrimination claims brought under the Americans with Disabilities Act.

Tennessee v. Lane

Tennessee v. Lane,[89] 541 U.S. 509 (2004), was a case in the Supreme Court of the United States involving Congress’s enforcement powers under section 5 of the Fourteenth Amendment. George Lane was unable to walk after a 1997 car accident in which he was accused of driving on the wrong side of the road. A woman was killed in the crash, and Lane faced misdemeanour charges of reckless driving. The suit was brought about because he was denied access to appear in criminal court because the courthouse had no elevator, even though the court was willing to carry him up the stairs and then willing to move the hearing to the first floor. He refused, citing he wanted to be treated as any other citizen, and was subsequently charged with failure to appear, after appearing at a previous hearing where he dragged himself up the stairs. The court ruled that Congress did have enough evidence that the disabled were being denied those fundamental rights that are protected by the Due Process clause of the Fourteenth Amendment and had the enforcement powers under section 5 of the Fourteenth Amendment. It further ruled that “reasonable accommodations” mandated by the ADA were not unduly burdensome and disproportionate to the harm.

What is the Rebound Effect?

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Introduction

The rebound effect, or rebound phenomenon, is the emergence or re-emergence of symptoms that were either absent or controlled while taking a medication, but appear when that same medication is discontinued, or reduced in dosage.

In the case of re-emergence, the severity of the symptoms is often worse than pre-treatment levels.

Examples

Sedative Hypnotics

Rebound Insomnia

Rebound insomnia is insomnia that occurs following discontinuation of sedative substances taken to relieve primary insomnia. Regular use of these substances can cause a person to become dependent on its effects in order to fall asleep. Therefore, when a person has stopped taking the medication and is ‘rebounding’ from its effects, he or she may experience insomnia as a symptom of withdrawal. Occasionally, this insomnia may be worse than the insomnia the drug was intended to treat.

Common medicines known to cause this problem are eszopiclone, zolpidem, and anxiolytics such as benzodiazepines and which are prescribed to people having difficulties falling or staying asleep.

Rebound Depression

Depressive symptoms may appear to arise in patients previously free of such an illness.

Daytime Rebound

Rebound phenomena do not necessarily only occur on discontinuation of a prescribed dosage. For example, daytime rebound effects of anxiety, metallic taste, perceptual disturbances which are typical benzodiazepine withdrawal symptoms can occur the next day after a short-acting benzodiazepine hypnotic wears off. Another example is early morning rebound insomnia which may occur when a rapidly eliminated hypnotic wears off which leads to rebounding awakeness forcing the person to become wide awake before he or she has had a full night’s sleep. One drug which seems to be commonly associated with these problems is triazolam, due to its high potency and ultra short half life, but these effects can occur with other short-acting hypnotic drugs. Quazepam, due to its selectivity for type1 benzodiazepine receptors and long half-life, does not cause daytime anxiety rebound effects during treatment, showing that half-life is very important for determining whether a night-time hypnotic will cause next-day rebound withdrawal effects or not. Daytime rebound effects are not necessarily mild but can sometimes produce quite marked psychiatric and psychological disturbances.

Stimulants

Rebound effects from stimulants such as methylphenidate or dextroamphetamine include stimulant psychosis, depression and a return of ADHD symptoms but in a temporarily exaggerated form. Up to a third of ADHD children experience a rebound effect when methylphenidate is withdrawn.

Antidepressants

Many antidepressants, including SSRIs, can cause rebound depression, panic attacks, anxiety, and insomnia when discontinued.

Antipsychotics

Sudden and severe emergence or re-emergence of psychosis may appear when antipsychotics are switched or discontinued too rapidly.

Alpha-2 Adrenergic Agents

Rebound hypertension, above pre-treatment level, was observed after clonidine, and guanfacine discontinuation.

Others

Other Rebound Effects

An example is the use of highly potent corticosteroids, such as clobetasol for psoriasis. Abrupt withdrawal can cause a much more severe case of the psoriasis to develop. Therefore, withdrawal should be gradual, diluting the medication with lotion perhaps, until very little actual medication is being applied.

Another example of pharmaceutical rebound is a rebound headache from painkillers when the dose is lowered, the medication wears off, or the drug is abruptly discontinued.

Continuous usage of topical decongestants (nasal sprays) can lead to constant nasal congestion, known as rhinitis medicamentosa.

On This Day … 31 August

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People (Deaths)

  • 1920 – Wilhelm Wundt, German physician, psychologist, and philosopher (b. 1832).

Wilhelm Wundt

Wilhelm Maximilian Wundt (16 August 1832 to 31 August 1920) was a German physiologist, philosopher, and professor, known today as one of the founders of modern psychology.

Wundt, who distinguished psychology as a science from philosophy and biology, was the first person ever to call himself a psychologist. He is widely regarded as the “father of experimental psychology”. In 1879, at University of Leipzig, Wundt founded the first formal laboratory for psychological research. This marked psychology as an independent field of study. By creating this laboratory he was able to establish psychology as a separate science from other disciplines. He also formed the first academic journal for psychological research, Philosophische Studien (from 1881 to 1902), set up to publish the Institute’s research.

A survey published in American Psychologist in 1991 ranked Wundt’s reputation as first for “all-time eminence” based on ratings provided by 29 American historians of psychology. William James and Sigmund Freud were ranked a distant second and third.

What is a Paradoxical Reaction?

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Introduction

A paradoxical reaction or paradoxical effect is an effect of a chemical substance, typically a medical drug, that is opposite to what would usually be expected. An example of a paradoxical reaction is pain caused by a pain relief medication.

Paradoxical reactions are more commonly observed in people with attention deficit hyperactivity disorder (ADHD).

Substances

Amphetamines

Amphetamines are a class of psychoactive drugs that are stimulants. Paradoxical drowsiness can sometimes occur in adults.

Antibiotics

The paradoxical effect or Eagle effect (named after H. Eagle who first described it) refers to an observation of an increase in survivors, seen when testing the activity of an antimicrobial agent. Initially when an antibiotic agent is added to a culture media, the number of bacteria that survive drops, as one would expect. But after increasing the concentration beyond a certain point, the number of bacteria that survive, paradoxically, increases.

Antidepressants

In rare cases antidepressants can make users obsessively violent or have suicidal compulsions, which is in marked contrast to their intended effect. This can be regarded as a paradoxical reaction but, especially in the case of suicide, may in at least some cases be merely due to differing rates of effect with respect to different symptoms of depression: If generalised overinhibition of a patient’s actions enters remission before that patient’s dysphoria does and if the patient was already suicidal but too depressed to act on their inclinations, the patient may find themselves in the situation of being both still dysphoric enough to want to commit suicide but newly free of endogenous barriers against doing so. Children and adolescents are more sensitive to paradoxical reactions of self-harm and suicidal ideation while taking antidepressants but cases are still very rare.

Antipsychotics

Chlorpromazine, an antipsychotic and antiemetic drug, which is classed as a “major” tranquilizer may cause paradoxical effects such as agitation, excitement, insomnia, bizarre dreams, aggravation of psychotic symptoms and toxic confusional states.

Barbiturates

Phenobarbital can cause hyperactivity in children. This may follow after a small dose of 20 mg, on condition of no phenobarbital administered in previous days. Prerequisity for this reaction is a continued sense of tension. The mechanism of action is not known, but it may be started by the anxiolytic action of the phenobarbital.

Benzodiazepines

Benzodiazepines, a class of psychoactive drugs called the “minor” tranquilisers, have varying hypnotic, sedative, anxiolytic, anticonvulsant, and muscle relaxing properties, but they may create the exact opposite effects. Susceptible individuals may respond to benzodiazepine treatment with an increase in anxiety, aggressiveness, agitation, confusion, disinhibition, loss of impulse control, talkativeness, violent behaviour, and even convulsions. Paradoxical adverse effects may even lead to criminal behaviour. Severe behavioural changes resulting from benzodiazepines have been reported including mania, schizophrenia, anger, impulsivity, and hypomania.

Paradoxical rage reactions due to benzodiazepines occur as a result of an altered level of consciousness, which generates automatic behaviours, anterograde amnesia and uninhibited aggression. These aggressive reactions may be caused by a disinhibiting serotonergic mechanism.

Paradoxical effects of benzodiazepines appear to be dose related, that is, likelier to occur with higher doses.

In a letter to the British Medical Journal, it was reported that a high proportion of parents referred for actual or threatened child abuse were taking medication at the time, often a combination of benzodiazepines and tricyclic antidepressants. Many mothers described that instead of feeling less anxious or depressed, they became more hostile and openly aggressive towards the child as well as to other family members while consuming tranquilizers. The author warned that environmental or social stresses such as difficulty coping with a crying baby combined with the effects of tranquilisers may precipitate a child abuse event.

Self aggression has been reported and also demonstrated in laboratory conditions in a clinical study. Diazepam was found to increase people’s willingness to harm themselves.

Benzodiazepines can sometimes cause a paradoxical worsening of EEG readings in patients with seizure disorders.

Barbiturates such as pentobarbital have been shown to cause paradoxical hyperactivity in an estimated 1% of children, who display symptoms similar to the hyperactive-impulsive subtype of attention deficit hyperactivity disorder. Intravenous caffeine administration can return these patients’ behaviour to baseline levels.

Causes

The mechanism of a paradoxical reaction has as yet (2019) not been fully clarified, in no small part due to the fact that signal transfer of single neurons in subcortical areas of the human brain is usually not accessible.

There are, however, multiple indications that paradoxical reactions upon – for example – benzodiazepines, barbiturates, inhalational anaesthetics, propofol, neurosteroids, and alcohol are associated with structural deviations of GABAA receptors. The combination of the five subunits of the receptor (see image) can be altered in such a way that for example the receptor’s response to GABA remains unchanged but the response to one of the named substances is dramatically different from the normal one.

There are estimates that about 2-3% of the general population may suffer from serious emotional disorders due to such receptor deviations, with up to 20% suffering from moderate disorders of this kind. It is generally assumed that the receptor alterations are, at least partly, due to genetic and also epigenetic deviations. There are indication that the latter may be triggered by, among other factors, social stress or occupational burnout.

What are the Adverse Effects of Olanzpine?

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Introduction

Below is a list of the adverse effects of the antipsychotic olanzapine, sorted by frequency of occurrence.

Very Common

Very common adverse effects of olanzapine, occurring more than 10%, include:

  • Weight gain (dose-dependent).
    • Weight gain of over 7% of a person’s initial body weight prior to treatment is in this category of very common too with some estimates of its incidence putting it at around 40.6%.
    • This adverse effect is most likely the result of its potent 5-HT2C receptor and H1 receptor blockade (or more specifically inverse agonism).
  • Somnolence (dose-dependent).
    • Tends to produce a moderate amount of sedation, less than clozapine and chlorpromazine but more than aripiprazole, amisulpride, paliperidone and sertindole and approximately that of quetiapine and risperidone.
  • Hyperprolactinemia elevated blood levels of the hormone, prolactin.
    • Prolactin is one of the hormones that plays a key role in lactation. Long-term uncontrolled hyperprolactinaemia can lead to bone demineralisation (osteoporosis) and an increased risk of fractures (breaks).
    • It tends to produce hyperlacticaemia less often than risperidone, paliperidone and the typical antipsychotics but more often than quetiapine and clozapine.
  • Hypertriglyceridaemia (elevated blood triglycerides).
  • Hypercholesterolaemia (elevated blood cholesterol levels).
  • Hyperglycaemia (elevated blood glucose levels).
    • This may be the result of olanzapine’s inhibitory effects on the M3 receptor which regulates the release of insulin from the pancreas.
  • Brain shrinkage (dose dependent).

Common

Common adverse effects of olanzapine, occurring from 1-10%, include:

  • Gynecomastia.
  • Extrapyramidal symptoms (EPS) (dose-dependent).
    • Tends to produce less extrapyramidal side effects than typical antipsychotics but more extrapyramidal side effects than sertindole, clozapine and quetiapine.
  • Mild and transient constipation and xerostomia (dry mouth).
  • Dizziness.
  • Weight gain of over 15% of one’s initial body weight.
    • Is reported to occur in approximately 7.1% of patients.
  • Glucosuria (glucose in the urine).
    • This is a consequence of hyperglycaemia.
  • Accidental injury.
  • Insomnia.
  • Orthostatic hypotension (a drop in blood pressure that occurs upon standing up).
  • Transient, asymptomatic elevations of hepatic aminotransferases (ALT, AST), especially in early treatment.
    • ALT & AST are liver enzymes which are often tested for as a measure of liver function.
  • Dyspepsia (indigestion).
  • Erectile dysfunction.
    • This is most likely the result of hyperprolactinaemia.
  • Decreased libido.
    • This is most likely the result of hyperprolactinaemia.
  • Rash.
  • Asthenia (weakness).
  • Fatigue.
  • Oedema the accumulation of fluid in the tissues of the body leading to swelling.
  • Akathisia an inner sense of restlessness that presents itself with the inability to stay still.
  • Parkinsonism tremor, muscle rigidity, reduced ability to move and being unstable on one’s feet.
  • Dyskinesia abnormal, involuntary, repetitive, and pointless movements.
  • Vomiting.
  • Coma.
  • Cardiac arrest.

Uncommon

Uncommon adverse effects of olanzapine, occurring from 0.1-1%, include:

  • Leukopenia a comparatively low white blood cell (the cells that defend the body from foreign invaders) count.
  • Neutropaenia a reduced neutrophil (the white blood cells that kill bacteria) count.
  • Bradycardia (low heart rate).
  • QTc interval prolongation (an abnormality in the electrical cycle of the heart).
  • Photosensitivity reaction.
  • Alopecia (hair loss).
  • Urinary incontinence.
  • Urinary retention, the inability to urinate.
  • Amenorrhea the cessation of menses (a woman’s menstrual cycles).
    • This is a complication of hyperprolactinaemia.
  • Breast enlargement (in either sex).
    • This is a complication of hyperprolactinaemia.
  • Galactorrhoea (expulsion of milk from the breasts that’s unrelated to pregnancy or lactation).
    • Most likely the result of hyperprolactinaemia.
  • High creatine phosphokinase (an abnormal laboratory finding).
  • Increased total bilirubin (a by product of the breakdown of haem – a part of blood cells that is used to carry oxygen).
    • In most people this is an indication of impaired liver function.
  • Abdominal pain.

Rare

Rare adverse effects of olanzapine, occurring from 0.01-0.1%, include:

  • Hepatitis.
  • Rash.
  • Seizures.
  • Glaucoma.
  • Blindness.

Very Rare (But Not Necessarily Causally Related)

Very rare adverse effects of olanzapine, occurring less than 0.01%, include:

  • Agranulocytosis, a potentially fatal drop in white blood cell count, basically an exaggerated form of leukopenia.
  • Thrombocytopaenia.
    • A drop in blood platelet counts which are involved in blood clotting.
  • Thromboembolism (blood clots; including pulmonary embolism and deep vein thrombosis).
  • Rhabdomyolysis (breakdown of muscle tissue leading to the release of myoglobin into the bloodstream which in turn damages the kidneys).
  • Alkaline phosphatase increased (an abnormal laboratory parameter).
  • Priapism (a painful and enduring erection).
  • Urinary hesitation.
  • Pancreatitis, swelling of the pancreas which supplies the body with insulin.
  • Neuroleptic malignant syndrome a potentially fatal complication of antipsychotic drug treatment.
    • Presents with hyperthermia, tremor, tachycardia (high heart rate), mental status change (e.g. confusion), etc.
  • Jaundice, which is basically when the body’s ability to clear a by product (called bilirubin) of the breakdown of an essential component of the blood called haem, is impaired leading to yellow discolouration of the skin, eyes and mucous membranes.
  • Diabetic coma.
  • Diabetic ketoacidosis.
    • Type II diabetes mellitus is basically where the body cannot effectively utilise sugars to produce energy due to the fact that its cells have become unresponsive to the hormone, insulin, which allows cells to utilise sugars for energy.
    • This in turn forces the body to burn fats for energy and fats require conversion to ketone bodies in order to be utilised by the cells of the body as an energy source.
    • The ketone bodies are acidic hence when the body is entirely reliant on these ketone bodies for energy the levels in the blood reaches a point where it overwhelms the body’s natural mechanisms to keep blood pH (a measure of acidity) within a safe range, leading to the blood becoming acidic which is potentially damaging to the tissues of the body due to the ability of acidic environments to denature the proteins of the body.
  • Anaphylactic reaction a potentially life-threatening allergic reaction.
  • Sudden cardiac death.