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 ACKNOWLEDGMENTS
Rebecca Fox-Gieg and Pam Bennett of Pearson deserve
special mention for their stewardship during the production
of this book. Additional thanks go to Jess Leighton, our out-
standing copyeditor; and to Billu Suresh, our project manager
at Pearson CSC, for their outstanding service. We are also
grateful to the reviewers for their helpful and supportive com-
ments: Katrina Cook, Texas A&M University-San Antonio;
Tara Jungersen, Nova Southwestern University; Jered Rose,
Bowling Green State University; and Nikki Vasilas, Lenoir
Ryne University.
vii
 ABOUT THE AUTHORS
Dr. Bradley T. Erford, PhD, LCPC, LPC, NCC, LP, LSP, is a
professor in the Human Development Counseling Program within
the Department of Human and Organizational Development at
the Peabody College of Education at Vanderbilt University.
He was the 2012–2013 President of the American Counseling
Association. He is the editor of Measurement and Evaluation
of Counseling and Development (MECD) and Senior Associate
Editor of the Journal of Counseling and Development (JCD). He
is the editor or author of more than 30 books. His research spe-
cialization falls primarily in development and technical analysis
of psychoeducational tests and has resulted in the publication of
numerous refereed journal articles, book chapters, and published
tests. He has held numerous leadership positions and has been
honored with awards many times by the American Counseling
Association (ACA) and ACA–Southern Region, the Associa-
tion for Assessment and Research in Counseling (AARC), and
the Maryland Counseling Association (MCA). Dr. Erford is a
Licensed Clinical Professional Counselor, Licensed Professional
Counselor, Nationally Certified Counselor, Licensed Psycholo-
gist, and Licensed School Psychologist. He is a graduate of the
University of Virginia (PhD in counselor education), Bucknell
University (MA in school psychology), and Grove City College
(BS in biology) and teaches courses in testing and measurement,
lifespan development, school counseling, research and evalua-
tion in counseling, and stress management.
Danica G. Hays, PhD, LPC, NCC, is professor of counseling
and executive associate dean in the College of Education at
the University of Nevada, Las Vegas. She is a recipient of the
Outstanding Research Award, Outstanding Counselor Educator
Advocacy Award, and Glen E. Hubele National Graduate Stu-
dent Award from the American Counseling Association (ACA)
as well as the Patricia B. Elmore Excellence in Measurement and
Evaluation Award and President’s Special Merit Award from the
Association of Assessment and Research in Counseling (AARC).
Dr. Hays served as Founding Editor of Counseling Outcome
Research and Evaluation, a national peer-refereed journal of the
AARC, and Editor of Counselor Education and Supervision, a
national peer-refereed journal of the Association for Counselor
Education and Supervision. She served as President of the AARC
in 2011–2012. Her research interests include qualitative method-
ology, assessment and diagnosis, trauma and gender issues, and
multicultural and social justice concerns in counselor prepara-
tion and community mental health. She has published numerous
articles and book chapters in these areas. In addition to this text,
she has authored, coauthored, or coedited five books to date:
Assessment in Counseling: Procedures and Practices (ACA),
Developing Multicultural Counseling Competence: A Systems
Approach (Pearson), Qualitative Inquiry in Clinical and Educa-
tional Settings (Guilford), A Counselor’s Guide to Career Assess-
ment Instruments (National Career Development Association),
and the ACA Encyclopedia of Counseling (ACA).
Stephanie A. Crockett, PhD, NCC, is an associate professor of
counseling at Oakland University (OU) and Program Coordi-
nator of the counseling PhD program. She has served in several
national leadership positions for the Association for Assessment
and Research in Counseling (AARC). She currently serves as
an editorial board member for both the Journal of Counseling
and Development and The Professional Counselor. Her research
and professional interests include counseling research methods
and assessment, gender issues in counseling, and career devel-
opment and counseling. She has published many refereed arti-
cles in professional counseling journals and authored several
book chapters. Dr. Crockett teaches courses in research meth-
ods, lifespan development, professional issues and counseling
ethics. She has received several national awards, including the
Leadership Fellow Award from Chi Sigma Iota, and the Glen E.
Hubele National Graduate Student Award from the American
Counseling Association.
ix

Introduction 1
CHAPTER 1 Professional Orientation
and Ethical Practice 5
CHAPTER 2 Social and Cultural
Diversity 31
CHAPTER 3 Human Growth and
Development 58
CHAPTER 4 Lifestyle and Career
Development 94
CHAPTER 5 Helping Relationships
CHAPTER 6 Group Work 158
CHAPTER 7 Assessment and Testing
BRIEF CONTENTS
CHAPTER 8 Research and Program
Evaluation 219
CHAPTER 9 From Envisioning to
Actualization: Marketing
Yourself in the 21st
Century 250
Practice Tests of the National Counselor
Examination and the Counselor Preparation
Comprehensive Examination 267
NCE Sample Test—Form A 270
NCE Sample Test—Form B 282
CPCE Sample Test—Form A 294
124 CPCE Sample Test—Form B 305
Appendix: Answers to Self-Check Quizzes 314
Glossary 315
References 345
180 Index 351
xi
 CONTENTS
Introduction 1
About the National Counselor Examination (NCE)
for Licensure and Certification 1
About the Counselor Preparation Comprehensive
Examination (CPCE) 2
Preparation Strategies for Success 2
Test-Taking Strategies 3
Chapter 1 Professional Orientation
and Ethical Practice 5
1.1 Introduction to Professional Orientation
and Ethical Practice 5
1.1.1 Key Historical Events in Counseling 6
1.1.2 Key Legal Issues in Counseling 6
1.1.3 Accreditation and the Council for
Accreditation of Counseling and Related
Educational Programs (CACREP) 11
1.1.4 Advocacy Counseling 11
1.1.5 Health Maintenance Organizations
(HMO) 11
1.1.6 Liability Insurance 12
1.1.7 Licensure 12
1.1.8 The National Board for Certified
Counselors 12
1.1.9 Practice Multiple-Choice Items:
Introduction to Professional Orientation
and Ethical Practices 13
1.2 Counseling Specializations 13
1.2.1 Clinical Mental Health Counseling 13
1.2.2 College Admissions Counseling 14
1.2.3 College Counseling 14
1.2.4 Rehabilitation Counseling 14
1.2.5 School Counseling 15
1.2.6 Other Types of Mental Health
Counseling 15
1.2.7 Counselor Supervision Models 16
1.2.8 Practice Multiple-Choice Items:
Counseling Specialization 17
1.3 Professional Organizations 17
1.3.1 American Association of State
Counseling Boards 17
1.3.2 American College Counseling
Association 17
1.3.3 American Counseling Association
(ACA) 17
1.3.4 American Mental Health Counselors
Association 18
1.3.5 American Rehabilitation Counseling
Association 18
1.3.6 American School Counselor
Association 18
1.3.7 Association for Adult Development and
Aging 18
1.3.8 Association for Assessment and Research
in Counseling 18
1.3.9 Association for Counselor Education and
Supervision 19
1.3.10 Association for Child and Adolescent
Counseling 19
1.3.11 Association for Creativity in
Counseling 19
1.3.12 Association for Humanistic
Counseling 19
1.3.13 Association for Lesbian, Gay,
Bisexual, and Transgender Issues
in Counseling 19
1.3.14 Association for Multicultural Counseling
and Development 19
1.3.15 Association for Specialists in Group
Work 20
1.3.16 Association for Spiritual, Ethical, and
Religious Values in Counseling 20
1.3.17 Chi Sigma Iota 20
1.3.18 Counselors for Social Justice 20
1.3.19 International Association of Addictions
and Offender Counselors 20
1.3.20 International Association of Marriage
and Family Counselors 20
1.3.21 Military and Government Counseling
Association 21
1.3.22 National Career Development
Association 21
1.3.23 National Employment Counseling
Association 21
1.3.24 Practice Multiple-Choice Items:
Professional Organizations 21
1.4 Ethical and Legal Issues 21
1.4.1 Ethics 21
1.4.2 ACA Code of Ethics 22
1.4.3 National Board for Certified Counselors
Code of Ethics 27
xiii
xiv Contents

1.4.4 Legal Issues in Counseling 27 2.4.3 Sexual Identity Development 46

1.4.5 Duty to Warn and Protect 28
1.4.6 Privileged Communication and
Confidentiality 29
1.4.7 Practice Multiple-Choice Items:
Ethical and Legal Issues 29
1.5 Key Points for Chapter 1: Professional
Orientation and Ethical Practice 30
Chapter 2 Social and Cultural
Diversity 31
2.1 Introduction to Social and Cultural Diversity 31
2.1.1 Culture and Multicultural
Counseling 32
2.1.2 Key Historical Events in Social and
Cultural Diversity 32
2.1.3 Key Ethical Issues in Social and Cultural
Diversity 32
2.1.4 Multicultural Counseling
Competence 33
2.1.5 Communication Patterns 33
2.1.6 Acculturation 34
2.1.7 Worldview 35
2.1.8 Practice Multiple-Choice Items:
Introduction to Social and Cultural
Diversity 35
2.2 Key Cultural Group Categories 36
2.2.1 Race 36
2.2.2 Ethnicity 37
2.2.3 Socioeconomic Status 37
2.2.4 Sex and Gender 37
2.2.5 Sexual Orientation 38
2.2.6 Spirituality 39
2.2.7 Disability 40
2.2.8 Practice Multiple-Choice Items:
Key Cultural Group Categories 40
2.3 Social Justice Concepts 40
2.3.1 Social Justice 40
2.3.2 Privilege and Oppression 41
2.3.3 Prejudice 41
2.3.4 Racism 42
2.3.5 Sexism 42
2.3.6 Resilience 42
2.3.7 Practice Multiple-Choice Items: Social
Justice Concepts 43
2.4 Cultural Identity Development 43
2.4.1 Racial Identity Development 43
2.4.2 Gender Identity Development 45
2.4.4 Spiritual Identity Development 47
2.4.5 Practice Multiple-Choice Items: Cultural
Identity Development 48
2.5 Counseling Racial and Ethnic Groups 48
2.5.1 African Americans 48
2.5.2 Arab Americans 49
2.5.3 Asian Americans 49
2.5.4 European Americans 49
2.5.5 Latin Americans 50
2.5.6 Native Americans 51
2.5.7 Multiracial Individuals 51
2.5.8 Practice Multiple-Choice Items:
Counseling Racial and Ethnic Groups 52
2.6 Counseling Other Cultural
Groups 52
2.6.1 Sexual Minority Clients 52
2.6.2 Gerontological Clients 53
2.6.3 Adolescents 53
2.6.4 International Students 53
2.6.5 Practice Multiple-Choice Items:
Counseling Other Cultural Groups 53
2.7 Additional Considerations in Multicultural
Counseling Practice 54
2.7.1 Addictions Counseling 54
2.7.2 Motivational Interviewing 54
2.7.3 Feminist Theory 55
2.7.4 Social Identity Theory 55
2.7.5 Social Influence Model 56
2.7.6 Sociometry 56
2.7.7 Practice Multiple-Choice Items:
Additional Considerations in
Multicultural Counseling Practice 56
2.8 Key Points for Chapter 2: Social and Cultural
Diversity 56
Chapter 3 Human Growth and
Development 58
3.1 Foundational Issues in Human Growth and
Development 58
3.1.1 Stages of Human Development 58
3.1.2 Types of Aging 59
3.1.3 Categorizing Theories of Human
Development 59
3.1.4 Special Designs in Human Development
Research 59
3.1.5 Practice Multiple-Choice Items:
Foundational Issues in Human Growth
and Development 60

3.2 The Central Nervous System 61
3.2.1 Development of the Central Nervous
System 61
3.2.2 Genetic Disorders 62
3.2.3 Practice Multiple-Choice Items:
The Central Nervous System 63
3.3 Learning Theories 63
3.3.1 Classical Conditioning 63
3.3.2 Operant Conditioning 64
3.3.3 Social Learning 65
3.3.4 The Dollard and Miller Approach 66
3.3.5 Practice Multiple-Choice Items: Learning
Theories 66
3.4 Cognitive Development 67
3.4.1 Jean Piaget’s Cognitive Developmental
Theory 67
3.4.2 Lev Vygotsky’s Cognitive Developmental
Theory 68
3.4.3 Cognition and Memory 68
3.4.4 Other Important Concepts in Cognitive
Development 69
3.4.5 Practice Multiple-Choice Items:
Cognitive Development 70
3.5 Language Development 71
3.5.1 Theories of Language Development 71
3.5.2 Important Concepts in Language
Development 71
3.5.3 Milestones in Early Language
Development 72
3.5.4 Communication Disorders 72
3.5.5 Practice Multiple-Choice Items:
Language Development 72
3.6 Personality Development 73
3.6.1 Psychosexual Theory of Sigmund
Freud 73
3.6.2 Psychosocial Theory of Erik
Erikson 74
3.6.3 Ego Development Theory of Jane
Loevinger 75
3.6.4 Humanistic Theory of Abraham
Maslow 75
3.6.5 The Five Factor Model 75
3.6.6 Ethological Theories of Konrad Lorenz,
John Bowlby, Mary Ainsworth, and
Harry Harlow 75
3.6.7 Identity Development 76
3.6.8 Sex Role and Gender Role
Development 76
3.6.9 Social Development 77
Contents xv
3.6.10 Adjustment to Aging and Death 77
3.6.11 Practice Multiple-Choice Items:
Personality Development 78
3.7 Moral Development 78
3.7.1 Lawrence Kohlberg 78
3.7.2 Carol Gilligan 79
3.7.3 Other Approaches to Understanding
Moral Development 80
3.7.4 Practice Multiple-Choice Items: Moral
Development 80
3.8 Lifespan Theories: Individual Task Development
and Milestones 81
3.8.1 The Developmental Milestone Approach
of Arnold Gesell 81
3.8.2 Robert Havighurst’s Developmental Task
Approach 81
3.8.3 Roger Gould’s Adult Developmental
Theory 82
3.8.4 Robert Peck’s Phase Theory of Adult
Development 82
3.8.5 Daniel Levinson’s Adult Male
Development Theory 83
3.8.6 Bronfenbrenner’s Ecological
Model 83
3.8.7 Women’s Development 83
3.8.8 Generational Considerations in Human
Development 84
3.8.9 Practice Multiple-Choice Items: Lifespan
Theories 84
3.9 Family Development and Issues 84
3.9.1 Family Development 84
3.9.2 Parenting Influences 85
3.9.3 Separation, Divorce, and
Remarriage 85
3.9.4 Maternal Employment 86
3.9.5 Abuse 86
3.9.6 Intimate Partner Violence 86
3.9.7 Practice Multiple-Choice Items:
Family Development and Issues 87
3.10 Crisis, Resilience, and Wellness 87
3.10.1 Crisis and Crisis Management 87
3.10.2 Risk and Resiliency Factors 89
3.10.3 Responding to Crises 89
3.10.4 Trauma Counseling 90
3.10.5 Conflict Resolution 91
3.10.6 Peer Mediation 91
3.10.7 Aggression 91
3.10.8 Wellness 92
xvi Contents
3.10.9 Self-Care Strategies 92
3.10.10 Practice Multiple-Choice Items: Crisis,
Resilience, and Wellness 92
3.11 Key Points For Chapter 3: Human Growth
and Development 92
Chapter 4 Lifestyle and Career
Development 94
4.1 Introduction to Career Development 95
4.1.1 Key Historical Events in Career
Development 95
4.1.2 Key People in Career Development 96
4.1.3 Ethical Issues in Career
Development 96
4.1.4 Key Legal Issues in Career
Development 97
4.1.5 Practice Multiple-Choice Items:
Introduction to Career Development 98
4.2 Key Concepts in Career Development 98
4.2.1 Career 98
4.2.2 Roles 98
4.2.3 Career Salience 99
4.2.4 Work Values 99
4.2.5 Career Interests 99
4.2.6 Career Adaptability 99
4.2.7 Career Adjustment 100
4.2.8 Job Satisfaction 100
4.2.9 Self-Efficacy 100
4.2.10 Occupational Stress 100
4.2.11 Practice Multiple-Choice Items: Key
Concepts in Career Development 100
4.3 Trait and Type Career Theories 101
4.3.1 Trait and Factor Theory 101
4.3.2 Theory of Work Adjustment 102
4.3.3 Holland’s Theory of Types 103
4.3.4 Myers-Briggs Type Theory 103
4.3.5 Brown’s Holistic Values-Based Theory of
Life Choice and Satisfaction 103
4.3.6 Practice Multiple-Choice Items: Trait and
Type Career Theories 104
4.4 Lifespan and Developmental Career
Theories 104
4.4.1 Gottfredson’s Theory of Circumscription,
Compromise, and Self-Creation 105
4.4.2 Lifespan, Life-Space Career Theory 105
4.4.3 Career Transition Theories 107
4.4.4 Practice Multiple-Choice Items:
Lifespan and Developmental Career
Theories 107
4.5 Special Focus Career Theories 107
4.5.1 Career Decision-Making Theories 107
4.5.2 Social Learning Theory 109
4.5.3 Social Cognitive Career Theory 109
4.5.4 Relational Approaches to Career
Development 110
4.5.5 Constructivist and Narrative
Approaches to Career
Development 110
4.5.6 Practice Multiple-Choice Items:
Special Focus Career Theories 111
4.6 Career Assessment 112
4.6.1 Interest Inventories 112
4.6.2 Personality Inventories 112
4.6.3 Values Inventories 112
4.6.4 Career Development Inventories 112
4.6.5 Practice Multiple-Choice Items: Career
Assessment 112
4.7 Labor Market and Sources of Occupational
Information 116
4.7.1 The U.S. Labor Market 116
4.7.2 Occupational Information 117
4.7.3 Evaluating Occupational
Information 118
4.7.4 Practice Multiple-Choice Items: Labor
Market and Sources of Occupational
Information 118
4.8 Career Counseling and Interventions 119
4.8.1 Career Counseling Defined 119
4.8.2 Career Counseling Competencies 119
4.8.3 The Structure of Career
Counseling 119
4.8.4 Career Counseling Interventions 120
4.8.5 Career Counseling for Diverse
Populations 120
4.8.6 Practice Multiple-Choice Items: Career
Counseling and Interventions 121
4.9 Career Development Program Planning,
Implementation, and Evaluation 121
4.9.1 Steps for Career Development Program
Planning 121
4.9.2 Steps for Career Development Program
Implementation 121
4.9.3 Steps for Career Development Program
Evaluation 122
4.9.4 Practice Multiple-Choice Items: Career
Development Program Planning,
Implementation, and Evaluation 122
4.10 Key Points for Chapter 4: Lifestyle and Career
Development 123

Chapter 5 Helping Relationships 124
5.1 Introduction to Helping Relationships 124
5.1.1 Wellness 125
5.1.2 Therapeutic Alliance 125
5.1.3 Resistance 126
5.1.4 Stages of Counseling 126
5.1.5 Stages of Change 126
5.1.6 Consultation 127
5.1.7 Psychological First Aid 128
5.1.8 Practice Multiple-Choice Items:
Introduction to Helping
Relationships 128
5.2 Counseling Skills 129
5.2.1 Basic Counseling Skills 129
5.2.2 Practice Multiple-Choice Items:
Counseling Skills 130
5.3 Psychodynamic Theories and
Interventions 131
5.3.1 Psychoanalysis 131
5.3.2 Neo-Freudian Approaches 132
5.3.3 Individual Psychology 132
5.3.4 Jungian Psychology 134
5.3.5 Practice Multiple-Choice Items:
Psychodynamic Theories and
Interventions 135
5.4 Cognitive-Behavioral Theories and
Interventions 136
5.4.1 Behavioral Counseling Techniques 136
5.4.2 Cognitive-Behavior Modification 137
5.4.3 Cognitive Therapy 137
5.4.4 Rational Emotive Behavior Therapy 138
5.4.5 Reality Therapy and Choice Theory 139
5.4.6 Practice Multiple-Choice Items:
Cognitive-Behavioral Theories and
Interventions 140
5.5 Humanistic-Existential Theories and
Interventions 140
5.5.1 Client-Centered Counseling 140
5.5.2 Existential Counseling 141
5.5.3 Gestalt Therapy 141
5.5.4 Practice Multiple-Choice Items:
Humanistic-Existential Theories and
Interventions 143
5.6 Postmodern Theories and Interventions 143
5.6.1 Narrative Therapy 143
5.6.2 Solution-Focused Brief Therapy 144
5.6.3 Practice Multiple-Choice Items:
Postmodern Theories and
Interventions 145
Contents xvii
5.7 Family Theories and Interventions 146
5.7.1 General Systems Theory 146
5.7.2 Bowen Family Systems Therapy 146
5.7.3 Experiential Family Counseling 148
5.7.4 Strategic Family Therapy 148
5.7.5 Milan Systemic Family Counseling 149
5.7.6 Structural Family Counseling 150
5.7.7 Practice Multiple-Choice Items: Family
Theories and Interventions 152
5.8 Other Counseling Theories and
Interventions 152
5.8.1 Integrated Counseling
Approach 152
5.8.2 Multimodal Therapy 152
5.8.3 Eye Movement Desensitization and
Reprocessing (EMDR) 153
5.8.4 Play Therapy 153
5.8.5 Transactional Analysis 154
5.8.6 Feminist Therapy 154
5.8.7 Dialectical Behavior Therapy 155
5.8.8 Acceptance and Commitment
Therapy 155
5.8.9 Mindfulness-Based Cognitive
Therapy 156
5.8.10 Practice Multiple-Choice Items:
Other Counseling Theories and
Interventions 156
5.9 Key Points for Chapter 5: Helping
Relationships 156
Chapter 6 Group Work 158
6.1 Foundational Issues in Group Work 158
6.1.1 Group Work History 158
6.1.2 Advantages and Challenges of
Group Work 160
6.1.3 Goals of Group Work 160
6.1.4 Curative Factors 161
6.1.5 Key Group Work Organizations 161
6.1.6 Ethical and Legal Issues in Group
Work 161
6.1.7 Association for Specialists in Group
Work: Best Practices Guidelines 162
6.1.8 Association for Specialists in Group
Work: Training Standards 162
6.1.9 Association for Specialists in Group
Work: Multicultural and Social Justice
Competence Principles for Group
Workers 162
6.1.10 Practice Multiple-Choice Items:
Foundational Issues in Group Work 162
xviii Contents
6.2 Types of Group Work 162
6.2.1 Practice Multiple-Choice Items: Types
of Group Work 163
6.3 Group Leadership 163
6.3.1 Leadership Tasks 163
6.3.2 Group Leader Training Standards 164
6.3.3 Leader Styles 164
6.3.4 Leader Traits 164
6.3.5 Leader Techniques 164
6.3.6 Handling Group Conflict and
Resistance 165
6.3.7 Co-Leadership 165
6.3.8 Practice Multiple-Choice Items: Group
Leadership 165
6.4 Group Member Roles 166
6.4.1 Types of Group Member Roles 166
6.4.2 Facilitating Member Development 166
6.4.3 Dealing with Challenging Group
Member Roles 167
6.4.4 Practice Multiple-Choice Items: Group
Member Roles 168
6.5 Planning for Groups 169
6.5.1 Planning for Group Work 169
6.5.2 Preparing Members 170
6.5.3 Practice Multiple-Choice Items: Planning
for Groups 171
6.6 Stages/Process of Group Work 171
6.6.1 Group Dynamics: Content and Process
Issues 171
6.6.2 Stages of Group Development 174
6.6.3 Practice Multiple-Choice Items: Stages
and Process of Group Work 176
6.7 Assessment and Evaluation in Group Work 176
6.7.1 Evaluating Groups 176
6.7.2 Assessment in Group Work 177
6.7.3 Practice Multiple-Choice Items:
Assessment and Evaluation in Group
Work 178
6.8 Theoretical Approaches to Group Work 178
6.9 Key Points for Chapter 6: Group Work 178
Chapter 7 Assessment and Testing 180
7.1 Introduction to Assessment 180
7.1.1 Key Historical Events in Assessment 181
7.1.2 Assessment Terminology in
Counseling 182
7.1.3 The Purpose of Assessment in
Counseling 182
7.1.4 Key Ethical Issues in Assessment 184
7.1.5 Key Legal Issues in Assessment 186
7.1.6 Sources of Information on
Assessments 186
7.1.7 Practice Multiple-Choice Items:
Introduction to Assessment 187
7.2 Key Principles of Test Construction 187
7.2.1 Validity 188
7.2.2 Reliability 189
7.2.3 Item Analysis 191
7.2.4 Test Theory 191
7.2.5 The Development of Instrument
Scales 192
7.2.6 Practice Multiple-Choice Items: Key
Principles of Test Construction 193
7.3 Derived Scores 194
7.3.1 The Normal Distribution 194
7.3.2 Norm-Referenced Assessment 195
7.3.3 Percentiles 195
7.3.4 Standardized Scores 195
7.3.5 Developmental Scores 197
7.3.6 Practice Multiple-Choice Items:
Derived Scores 197
7.4 Assessment of Ability 198
7.4.1 Achievement Tests 198
7.4.2 Aptitude Tests 200
7.4.3 Intelligence Tests 201
7.4.4 High Stakes Testing 202
7.4.5 Practice Multiple-Choice Items:
Assessment of Ability 203
7.5 Clinical Assessment 204
7.5.1 Assessment of Personality 204
7.5.2 Informal Assessments 206
7.5.3 Other Types of Assessments 207
7.5.4 Practice Multiple-Choice Items: Clinical
Assessment 208
7.6 Special Issues in Assessment 210
7.6.1 Bias in Assessment 210
7.6.2 Test Translation and Test
Adaptation 211
7.6.3 Child and Adolescent Assessments 211
7.6.4 Computer-Based Testing 212
7.6.5 Practice Multiple-Choice Items: Special
Issues in Assessment 212
7.7 Diagnosis of Mental Disorders 212
7.7.1 Using the DSM-5 212
7.7.2 Neurodevelopmental Disorders 213

7.7.3 Schizophrenia Spectrum and Other
Psychotic Disorders 213
7.7.4 Bipolar and Related Disorders 214
7.7.5 Depressive Disorders 214
7.7.6 Anxiety Disorders 214
7.7.7 Obsessive-Compulsive and Related
Disorders 214
7.7.8 Trauma and Stressor-Related
Disorders 214
7.7.9 Dissociative Disorders 215
7.7.10 Somatic Symptom and Related
Disorders 215
7.7.11 Feeding and Eating Disorders 215
7.7.12 Elimination Disorders 215
7.7.13 Sleep–Wake Disorders 215
7.7.14 Sexual Dysfunctions 215
7.7.15 Gender Dysphoria 215
7.7.16 Disruptive, Impulse Control,
and Conduct Disorders 215
7.7.17 Substance-Related and Addictive
Disorders 216
7.7.18 Neurocognitive Disorders 216
7.7.19 Personality Disorders 216
7.7.20 Paraphilic Disorders 216
7.7.21 Practice Multiple-Choice
Items: Diagnosis of Mental
Disorders 217
7.8 Key Points for Chapter 7: Assessment 217
Chapter 8 Research and Program
Evaluation 219
8.1 Introduction to Research and Program
Evaluation 219
8.1.1 Key Paradigms in Research and Program
Evaluation 220
8.1.2 Key Ethical Considerations in Research
and Program Evaluation 220
8.1.3 Key Legal Considerations in Research
and Program Evaluation 220
8.1.4 Practice Multiple-Choice Items:
Introduction to Research and Program
Evaluation 221
8.2 Key Concepts in Research and Program
Evaluation 221
8.2.1 Variables 221
8.2.2 Research Questions 222
8.2.3 Research Hypotheses and Hypothesis
Testing 222
8.2.4 Sampling Considerations 223
Contents xix
8.2.5 Experimental and Control
Conditions 224
8.2.6 Internal Validity 224
8.2.7 External Validity 226
8.2.8 Practice Multiple-Choice Items: Key
Concepts in Research and Program
Evaluation 226
8.3 Broad Types of Research 226
8.3.1 Specialized Types of Research
Designs 227
8.3.2 Practice Multiple-Choice Items: Broad
Types of Research 228
8.4 Quantitative Research Design 228
8.4.1 Nonexperimental Research
Designs 229
8.4.2 Considerations in Experimental Research
Designs 229
8.4.3 Experimental Research Designs 230
8.4.4 Single-Subject Research Designs 231
8.4.5 Practice Multiple-Choice Items:
Quantitative Research Design 232
8.5 Descriptive Statistics 232
8.5.1 Presenting the Data Set 233
8.5.2 Measures of Central Tendency 234
8.5.3 Variability 235
8.5.4 Skewness 235
8.5.5 Kurtosis 235
8.5.6 Practice Multiple-Choice Items:
Descriptive Statistics 236
8.6 Inferential Statistics 237
8.6.1 Correlation 237
8.6.2 Regression 238
8.6.3 Parametric Statistics 238
8.6.4 Nonparametric Statistics 239
8.6.5 Factor Analysis 239
8.6.6 Meta-Analysis 240
8.6.7 Practice Multiple-Choice Items:
Inferential Statistics 240
8.7 Qualitative Research Design 241
8.7.1 Qualitative Research Traditions 241
8.7.2 Purposive Sampling 242
8.7.3 Qualitative Data Collection
Methods 243
8.7.4 Qualitative Data Management and
Analysis 244
8.7.5 Trustworthiness 244
8.7.6 Practice Multiple-Choice Items:
Qualitative Research Design 245
xx Contents

8.8 Program Evaluation 245 9.5 Securing a Job the Old-Fashioned Way 254
8.8.1 Key Terms of Program 9.5.1 Preparing a Curriculum Vita or
Evaluation 245 Résumé 254
8.8.2 General Steps in Program 9.5.2 Using Your Résumé or CV 255
Evaluation 246 9.5.3 Cover Letters 259
8.8.3 Needs Assessments 246 9.5.4 The Job Search 260
8.8.4 Process Evaluation 247 9.5.5 Landing the Interview and Following
8.8.5 Outcome Evaluation 247 Up 261
8.8.6 Efficiency Analysis 247 9.6 Carving Out Your New-Age Niche 262
8.8.7 Program Evaluation Models and 9.6.1 Reaching Out with Social
Strategies 247 Networking 262
8.8.7 Practice Multiple-Choice Items: 9.6.2 Selling Yourself on the Virtual
Program Evaluation 248 Job Market 263
8.9 Key Points for Chapter 8: Research 9.6.3 Building a Professional Website 263
and Program Evaluation 248 9.6.4 Virtual Ethics and Liabilities 264
9.7 The Advantages of Continued Learning 264
Chapter 9 From Envisioning to Actualiza-
tion: Marketing Yourself in the 9.7.1 Keep Up to Date 264
21st Century 250 9.7.2 Become an Expert 265
9.1 Preview 250 9.8 Summary 266
9.2 Marketing Yourself in the 21st Century 250 Practice Tests of the National Counselor
9.3 Temet Nosce 251 Examination and the Counselor Preparation
Comprehensive Examination 267
9.3.1 Select Strengths 251
NCE Sample Test—Form A 270
9.3.2 Examine Values, Biases, and Beliefs 251 NCE Sample Test—Form B 282
9.3.3 Live with Limitations 252 CPCE Sample Test—Form A 294
9.3.4 Formulate Your Counseling CPCE Sample Test—Form B 305
Approach 252 Appendix: Answers to Self-Check Quizzes 314
9.4 Understanding the Field Around You 252 Glossary 315
9.4.1 Using Networking Opportunities References 345
and Embracing Mentorship 254 Index 351
 INTRODUCTION
Before delving into each of the CACREP core content areas,
it is important to present some introductory information about
the NCE and CPCE and some test-preparation and test-taking
strategies for mastering the NCE and CPCE.
ABOUT THE NATIONAL COUNSELOR
EXAMINATION (NCE) FOR LICENSURE
AND CERTIFICATION
To obtain certification from the National Board for Certified
Counselors (NBCC), professional counselors must first pass the
National Counselor Examination for Licensure and Certifica-
tion (NCE), which NBCC creates and administers. Counselors
who pass the exam and meet NBCC’s standards of education
and training are entitled to receive NBCC’s general practitioner
credential, the National Certified Counselor (NCC) creden-
tial. Although taking and passing the NCE is voluntary, many
states require the NCE for their own licensure and credential-
ing purposes. One of the primary benefits of taking the NCE
and working toward the NCC is that the credential is nationally
recognized and strengthens the credential holder’s professional
reputation (NBCC, 2019b).
The NCE is a paper-and-pencil multiple-choice test. It
contains 200 multiple-choice questions, which test-takers are
allowed up to four hours to complete. The NCE aims to assess
test-takers’ knowledge and understanding of areas thought to be
essential for effective and successful counseling practice. The
NCE’s test questions stem from CACREP’s (2016) eight core
content areas and five work behaviors. The eight content areas
and the topics they cover are
1. Professional Orientation and Ethical Practice. Pro-
fessional counselors’ roles and functions; history and
philosophy of the counseling profession; professional
credentialing; professional organizations; legal and eth-
ical standards.
2. Social and Cultural Foundations. Multicultural and plu-
ralistic trends; theories of multicultural counseling; iden-
tity development and social justice; strategies for working
with and advocating for diverse populations; counselors’
roles in developing cultural self-awareness.
3. Human Growth and Development. Theories of individ-
ual and family development across the lifespan; learning
theories; personality, cognitive, and moral development;
normal and abnormal behavior.
4. Career and Lifestyle Development. Career develop-
ment theories and decision-making models; vocational
assessment instruments and techniques relevant to career
planning and decision making; the relationship between
work, leisure, and family; career counseling for specific
populations.
5. Helping Relationships. Wellness and prevention; essential
interviewing and counseling skills; counseling theories;
family theories and related interventions; counselor char-
acteristics and behaviors that influence helping processes.
6. Group Work. Principles of group dynamics; theories of
group counseling; group leadership styles; methods for
evaluation of effectiveness.
7. Assessment and Testing. Basic concepts of standardized
and nonstandardized testing; statistical concepts associ-
ated with assessment and testing; principles of validity
and reliability; interpretation of testing results; ethical and
legal consideration in assessment and testing.
8. Research and Program Development. Qualitative and
quantitative research designs; descriptive and inferen-
tial statistics; program evaluation and needs assessment;
research’s role in the use of evidence-based practices; eth-
ical and cultural considerations in research.
The NBCC seeks to reflect the actual work that profes-
sional counselors do by incorporating work behavior categories
into the NCE. The five work behaviors provide the context for
the eight CACREP content areas. The following are the five
categories:
1. Fundamental Counseling Issues
2. Counseling Process
3. Diagnostic and Assessment Services
4. Professional Practice
5. Professional Development, Supervision, and Consultation
The NCE is administered throughout the United States
two times each year (April and October), and each adminis-
tration of the NCE involves a varying set of questions from
the NCE test item bank (NBCC, 2019a). Of the 200 multiple-
choice questions administered, only 160 count toward the
test-takers’ final score. Thus, the highest score an examinee
can receive on the NCE is 160. The NBCC includes the 40
remaining questions for field-testing purposes to determine
whether these 40 questions may be suitable for inclusion in
future examinations. Examinees are not informed of which
questions are scored. Each multiple-choice question has four
answer choices, with only one correct answer per question.
Test-takers are not penalized for guessing, so examinees
should be sure to select an answer for each question. Accord-
ing to the NBCC, the questions on the test do not equally rep-
resent the eight content areas. The NCE has 30 professional
orientation and ethical practice items, 11 social and cultural
diversity items, 12 human growth and development items, 19
career development items, 36 helping relationship items, 16
group work items, 20 assessment items, and 16 research and
program evaluation items.
The minimum passing score for the NCE changes for each
examination and is decided according to a modified Angoff pro-
cedure, which calculates the likelihood that a nominally skilled
individual would answer each question correctly and then, on
the basis of that information, determines a cutoff score for the
1
2 Introduction
entire set of items. Thus, the NCE is a criterion-referenced test,
and the total score is interpreted as pass or fail based on a deter-
mined cutoff score. Usually within eight weeks after taking the
test, candidates receive their score report in the mail. The score
report includes candidates’ scores in each of the 13 domains
(delineated above), their score for the entire test, and the min-
imum passing score for the version of the NCE the examinee
completed.
ABOUT THE COUNSELOR PREPARATION
COMPREHENSIVE EXAMINATION (CPCE)
The Counselor Preparation Comprehensive Examination
(CPCE) was created by the Research and Assessment Corpo-
ration for Counseling (RACC) and the Center for Credentialing
and Education (CCE), both affiliates of NBCC, for use in col-
leges and universities with master’s programs in counseling.
Over 330 colleges and universities use the CPCE for program
evaluation and, frequently, as an exit exam (Center for Cre-
dentialing and Education, 2009). Results of the test give an
educational institution a sense of their students’ and their pro-
gram’s strengths and weaknesses in relation to national data.
In addition, many colleges and universities use this examina-
tion to encourage their students to engage in frequent, cumula-
tive studying and reviewing of the information learned in their
courses and field experiences.
The format of the CPCE resembles the NCE. The
CPCE comprises 160 questions, with 20 questions for each
of the eight CACREP areas. Only 17 questions from each
area count toward the test-takers’ score, which means that
the highest score a person can achieve on the examination is
136. Because the CPCE is based on the same eight CACREP
areas as the NCE, students have the ability to simultaneously
prepare for both examinations. However, the CPCE does not
offer a cutoff score to indicate a passing or failing score;
instead, university program faculty are left with that respon-
sibility if they intend to use the CPCE scores for high-stakes
evaluation decisions.
PREPARATION STRATEGIES FOR SUCCESS
Taking the NCE or CPCE is undoubtedly an important event in
your counseling career. Although the breadth of expected knowl-
edge can be overwhelming—even intimidating—mastering
the domain of knowledge of essential counseling information
is definitely possible. Remember, you have already learned a
large portion of this information in your classes. So, to prepare
for these tests, much of your time will be dedicated to reviewing
previously mastered information and concepts and ensuring that
you understand how to apply them. Before you start working
through this study guide, consider the following strategies for
success as you work toward your test date.
1. Manage your time and plan ahead. Neither the NCE nor
the CPCE lends itself to cramming; therefore, it is much
more advantageous to begin studying ahead of time.
One of the easiest ways to make the tasks of learning
and reviewing so much information easier is to break
up the task into manageable sections. Write out a study
schedule for yourself, and plan on reviewing only small
segments of information at each study session so that
you do not become overwhelmed or frustrated. It may
be helpful for your schedule to include when you will
study (e.g., the date and time), what you will study
(e.g., the material and any page numbers), and how you
will study (e.g., read, highlight key terms, and answer
multiple-choice questions). It is also important to sched-
ule time off from studying. Allowing yourself to mentally
recharge will help you approach the material with greater
clarity and focus. Do not put yourself at a disadvantage
by procrastinating.
2. Practice. Practice is a key factor in preparing for both the
NCE and CPCE. Specifically, it is important to be famil-
iar with the test format and types of questions that will
be asked on each exam. This study guide is packed with
sample questions similar to those that you will encounter
on the NCE and CPCE. The more familiar you are with
applying this information to sample questions, the better
prepared you will be for the actual tests.
3. Apply rather than memorize. Although you may feel
pressure to memorize everything word for word, doing
so is not an effective study strategy. Both the NCE and
CPCE will require you to apply the knowledge you have
gained. Nor is it useful to memorize the test questions
you review during your preparation for the exams. Each
administration of the NCE and CPCE includes new ques-
tions, so you will not find any questions in this study
guide that will occur exactly as written on future NCEs
or CPCEs. Of course, some of the questions in this guide
will resemble some of the actual questions. After all, the
questions all measure the same domain of knowledge.
But it is a much better use of your time to master the
domain of knowledge presented in this guide than to
master an item set.
4. Employ a study strategy. The use of a study strategy can
help you to both learn and apply the material you study.
One of the most well-known strategies for retaining the
material you read is Survey, Question, Read, Recite, and
Review (SQ3R). Specifically, this strategy recommends
first surveying the material’s words in boldface type,
tables, headings, and introductory sentences. Next, you
are advised to turn headings and boldface words into
questions, then to read the text to answer the previously
developed questions. Finally, you should restate the
material in your own words and engage in an ongoing
process of review. Other study strategies that can be
employed to assist you in reading and reviewing the test
material include taking notes, highlighting key words
and phrases, reviewing key words presented in the glos-
sary, reviewing flash cards, and forming a peer study
group. Given that there are numerous study strategies
and that everyone learns differently, it is important for

you to find and use the strategies that will work best
for you.
5. Give yourself positive reinforcements. Studying for the
NCE and CPCE is hard work. Be sure to reward yourself
with enjoyable activities or treats as you work through
the study material. Build in time between study sessions
to relax, too.
6. Apply the Premack principle to your study schedule.
The Premack principle demands that high-frequency
behaviors (i.e., what people like to do) should follow
low-frequency behaviors (i.e., what people don’t like
to do); thus, you should do what you don’t want to do
before you do what you do want to do! As pertains to
studying for the NCE or CPCE, complete a period of
study and follow it with an activity that you find more
enjoyable and rewarding.
7. Seek accommodations. If you have a disability and will
need accommodations while taking the NCE, it is your
responsibility to contact the NBCC prior to your test date.
E-mails can be sent to examinations@nbcc.org, or you
can contact a representative at (336) 547-0607. If you
decide to send an e-mail regarding accommodations,
include your name, address, phone number, and state or
residence, along with your question or request. When tak-
ing the CPCE, notify your program faculty ahead of time
regarding your need for accommodations.
8. Take good care of yourself before the exam. Keep in
mind that cramming the night before the exam will most
likely make you more anxious, so try instead to engage in
a relaxing activity that will calm your nerves and enable
you to get a good night’s sleep. Make sure that you are
fully rested and have had a nutritious breakfast before tak-
ing the exam so that you will be mentally alert and focused
when you arrive at the test center.
9. Arrive prepared for the examination. Remember to bring
several sharp #2 pencils, your admission ticket, and two
forms of identification (one with a photo). If you are not
familiar with the area where you will take the test, print
out directions beforehand. Finally, be sure to arrive at
least 30 minutes early so that you are not rushing before
the exam.
TEST-TAKING STRATEGIES
With successful preparation, counselors and counselor trainees
will have the necessary competence and confidence when taking
the NCE and CPCE. In addition, mastering these exams involves
several strategies to use while taking the exam itself. During the
exam, remember the following:
1. Answer all questions. As mentioned, you will not be
penalized for guessing. If you do not know the correct
answer to a question, it is better to use your common sense
and guess than to leave the answer blank.
2. Make educated guesses. You are better off making an
educated guess about a question than leaving it blank.
Introduction 3
With no penalty for guessing, you have a 25% chance
of guessing correctly, whereas if you leave the ques-
tion blank you will automatically receive zero points
for that question. When guessing, start by eliminating
obviously incorrect answers and then use cues and
common sense to infer which remaining answer makes
the most sense.
3. Pace yourself. On the NCE, you will have 4 hours to
answer 200 questions, which gives you 60 minutes for
every 50 questions. Do not spend more than 1 minute on
each question on your initial pass through the items. If you
are unsure of the answer to a question, skip it and return to
it later so that you give yourself adequate time to respond
to the questions that you are sure about first.
4. Stay calm. No doubt you have learned some useful
relaxation techniques over the years to help you through
school. Likely, you have also learned counseling tech-
niques to help your clients cope with stress. Use these
skills to help you through your exam. For example, if
you find yourself stressed during the test, try some deep
breathing exercises, progressive muscle relaxation, pos-
itive self-talk, or visual imagery to help alleviate some
of your anxiety.
5. Think and read carefully. Some questions on the NCE
and CPCE will include qualifiers that ask you to choose
the answer that is “not true” or the “best” choice. The
former asks you to choose the answer that does not
accurately answer the question. Regarding “best” choice
questions, a question may have four answer options,
several of which may seem right, and your task will
be to select the choice that is better than all the others.
Therefore, make sure you read each question and all of
the possible answer options thoroughly before marking
your response. For example, the first answer choice you
read may seem correct, but perhaps the second, third, or
fourth option is even better, so do not be tempted to rush
through a question just because one of the first choices
you read seems to fit.
6. Skip difficult or confusing questions. All questions are
worth the same number of points, so if you are hung up
on a question, skip it and come back to it later, or make
a guess. Spending too much time on questions you are
unsure about takes away precious time from questions to
which you do know the answers.
7. Check your answer sheet frequently. Pay close atten-
tion to your answer sheet to be sure that you are marking
answers to the correct questions, especially if you are tem-
porarily skipping some questions. Place a question mark,
hyphen, or some other symbol next to the questions you
are skipping so that you do not accidentally mark that
question with the answer to a different item.
8. Keep your answer sheet neat. If you need to write down
anything to assist you in working through a question,
use your response booklet. Your answer sheet will be
optically scanned, so it is important that you completely
color in all of your answer choices and avoid leaving
4 Introduction
stray marks on the answer sheet. If you put a question
mark or hyphen next to an item you want to come back
to, make sure you erase it after you have returned and
filled in the answer.
9. Stay focused. Ignore any distractions that arise. Instead,
keep your concentration centered on the test questions.
Four hours is adequate time to complete the test if you
maintain your focus.
10. Keep the test in perspective. You are not expected to
receive a perfect score on these tests, and you can get
many questions wrong and still pass, so do not stress out
if you do not know the answer to every question. Study,
practice, prepare, and try your best—that is all you can do!
Note: Starting in 2017–2018, the CPCE will be offered
as a computer administered examination to universities.
CHAPTER 1
Professional Orientation and Ethical
Practice

1.1 INTRODUCTION TO PROFESSIONAL ORIENTATION AND ETHICAL

PRACTICE
Professional orientation and ethical practice encompass much of the counseling curriculum. Professional
counselors must become very familiar with ethical and legal practice considerations and with historical
perspectives and advocacy models. Counselors also must understand the roles of professional organi-
zations and counseling specialties in counseling practice, as well as the diverse nature of credentialing.
Administrations of the NCE include (in addition to some trial items that do not count) 30 scored
items (of the 160 total, or about 19%) designed to measure professional issues and ethical practice
(rank = 2 of 8; the second most items of any of the eight domains). The average item difficulty index
was .74 (rank = 1 of 8; the easiest domain of item content), meaning that the average item in this domain
was correctly answered by 74% of test-takers.
Over the past several years, administrations of the CPCE have included 17 scored items designed
to measure professional issues and ethical practice, plus several trial items that do not count in your score.
The average item difficulty index was .68, meaning that the average item in this domain was correctly
answered by 68% of test-takers, which made this set of items among the easiest on the examination.
The Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2016)
defined standards for Professional Orientation and Ethical Practice as follows:
studies that provide an understanding of the following aspects of professional functioning:
a. history and philosophy of the counseling profession and its specialty areas;
b. the multiple professional roles and functions of counselors across specialty areas and
their relationships with human service and integrated behavioral health care systems,
including interagency and interorganizational collaboration and consultation;
c. counselors’ roles and responsibilities as members of interdisciplinary community
outreach and emergency management response teams;
d. the role and process of the professional counselor advocating on behalf of the
profession;
e. advocacy processes needed to address institutional and social barriers that impede
access, equity, and success for clients;
f. professional counseling organizations, including membership benefits, activities, ser-
vices to members, and current issues;
g. professional counseling credentialing, including certification, licensure, accreditation
practices and standards, and the effects of public policy on these issues;
h. current labor market information relevant to opportunities for practice within the
counseling profession;
i. ethical standards of professional counseling organizations and credentialing bodies,
and applications of ethical and legal considerations in professional counseling;
j. technology’s impact on the counseling profession;
k. strategies for personal and professional self-evaluation and implications for practice;
l. self-care strategies appropriate to the counselor role; and
m. the role of counseling supervision in the profession.

5
6 Chapter 1 • Professional Orientation and Ethical Practice

Each of these standards is addressed throughout Chapter 1.
In the remainder of this first section, we discuss key historical
events in counseling; key legal issues, including important laws,
abuse, and minor consent; accreditation and CACREP; advo-
cacy counseling; health maintenance organizations (HMOs); lia-
bility insurance; licensure; and the National Board for Certified
Counselors (NBCC).
1.1.1 Key Historical Events in Counseling
The counseling profession today comprises counselors who work
in a myriad of settings, from educational institutions and hospi-
tals to community health centers. As evidenced by the numerous
counseling specializations and associations, counseling is an
inclusive profession dedicated to meeting the needs of diverse
individuals and families at every stage of the life cycle. However,
the counseling profession had its genesis in the late 1800s with
vocational guidance. During the following decades, individuals
began introducing additional approaches to counseling and types
of counseling services to the public to promote the wellness of
clients and students in need, and the profession slowly expanded
from its vocational guidance roots. The timeline in Table 1.1
highlights some of the key historical events that transformed the
counseling profession into the diverse field that it is today.
1.1.2 Key Legal Issues in Counseling
It is the responsibility of professional counselors to abide by
the American Counseling Association (ACA) Code of Ethics
(2014), which provides counselors with mandatory ethics rules
they must follow and aspirational ethics rules they should fol-
low if they want to meet the highest standards of professional
practice and conduct (Remley & Herlihy, 2016). Likewise, it is
also the duty of professional counselors to be knowledgeable of
and adhere to applicable laws. The principal difference between
ethics and laws is that ethics are developed by associations to
help members practice in a reputable manner, whereas laws are
included in the penal code and often carry more serious conse-
quences when individuals fail to comply with them. Violation of
ethical standards may carry sanctions, but those penalties vary
greatly and are determined by ethics committees rather than
courts. Although the law trumps ethics in all circumstances, pro-
fessional counselors rarely have to violate ethical standards to
follow the law. When studying for the NCE or CPCE, counsel-
ors should become thoroughly familiar with the NBCC Code of
Ethics (NBCC, 2016; see www.nbcc.org/ethics/) and the ACA
Code of Ethics (ACA, 2014; see http://www.counseling.org/
Resources/aca-code-of-ethics.pdf; and see Section 1.4) and be
able to apply these ethical concepts to practice situations. This

TABLE 1.1 Timeline of Historical Events.

• Late 1800s—Vocational guidance counseling emerges as a result of the Industrial Revolution and social reform movements.
• Early 1900s—Frank Parsons, heralded as the founder of vocational guidance, opens the Bureau of Vocational Guidance in Boston,
which helps match individuals with suitable careers based on their skills and personal traits.
• 1908—Frank Parsons dies, and his influential book Choosing a Vocation is published posthumously.
• 1913—The National Vocational Guidance Association (NVGA) is founded.
• 1913—Clifford Beers, the leader of the mental health movement, which advocated for the construction of mental health clinics
and more humane treatment of institutionalized patients with psychological disorders, founds the Clifford Beers Clinic in New
Haven, Connecticut, considered the first outpatient mental health clinic in America.
• 1930s—E. G. Williamson creates the Minnesota Point of View, a trait and factor theory considered to be one of the first
counseling theories.
• 1932—The Wagner O’Day Act is passed, which creates U.S. Employment Services to aid the unemployed in finding work through
vocational guidance.
• 1940s and 1950s
• Carl Rogers’ humanistic approach to psychology gains widespread support in the counseling profession.
• Soldiers return home after World War II and increase the need for counseling, readjustment, and rehabilitation services.
• Increased numbers of counselors begin working full-time at postsecondary educational institutions, community agencies, and
vocational rehabilitation centers.
• More associations sprout up to help new counseling specializations form a unified and professional identity.
• 1952—To gain a larger voice in the counseling field, the American Personnel and Guidance Association (APGA; since renamed the
American Counseling Association [ACA]) is formed as a union among the National Vocational Guidance Association (NVGA; since
renamed the National Career Development Association [NCDA]), the National Association of Guidance and Counselor Trainers
(NAGCT; since renamed the Association for Counselor Education and Supervision [ACES]), the Student Personnel Association for
Teacher Education (SPATE; since renamed the Counseling Association for Humanistic Education and Development [C-AHEAD] and
most recently the Association for Humanistic Counseling [AHC]), and the American College Personnel Association (ACPA).
• 1952—The American School Counselor Association (ASCA) is formed and becomes a division of APGA the next year.
• 1958—Congress passes the National Defense Education Act (NDEA) in response to the launch of the Sputnik satellite in 1957,
which signaled that the Russians were leading in the Space Race. The NDEA provides schools with increased funds to improve their
curriculum and hire school counselors to pick out students showing promise in math and science.
(Continued)
 Chapter 1 • Professional Orientation and Ethical Practice 7

TABLE 1.1 Timeline of Historical Events. (Continued)

• 1958—The American Rehabilitation Counseling Association (ARCA), a division of APGA, is chartered.
• 1961—APGA publishes its first code of ethics.
• 1963—President Lyndon Johnson signs into law the Community Mental Health Act, which allots money for the creation of mental
health centers.
• 1965—The Association for Measurement and Evaluation in Guidance (AMEG), currently known as the Association for Assessment
and Research in Counseling (AARC), is chartered as a division of APGA.
• 1966—The National Employment Counseling Association (NECA), a division of APGA, is chartered.
• 1970s
• Legislation for individuals with disabilities emerges, leading to a heightened demand for rehabilitation counselors and school
counselors.
• Individuals in the counseling field publish books and articles that increase the counseling profession’s interest in multicultural
issues, such as cultural identity development, multicultural awareness, racism, and counseling minorities.
• 1972—The Association for Multicultural Counseling and Development (AMCD), a division of APGA, is founded.
• 1973—The Association for Specialists in Group Work (ASGW), a division of APGA, is created.
• 1974—The Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) and the International Association of
Addictions and Offender Counselors (IAAOC), both divisions of APGA, are chartered.
• 1975—The U.S. Supreme Court’s decision in Donaldson v. O’Connor results in the deinstitutionalization of patients in state mental
hospitals. This precedent-setting decision was one of the most significant in mental health law. It barred mental institutions from
committing individuals involuntarily if they were not an immediate threat to themselves or other people.
• 1976—Virginia is the first state to offer counselors the option to seek licensure.
• 1978—The American Mental Health Counselors Association (AMHCA), a division of APGA, is chartered.
• 1981—The Council for Accreditation of Counseling and Related Educational Programs (CACREP) is established to provide
accreditation for master’s and doctoral programs in counseling that adhere to its standards of preparation.
• 1982—The National Board for Certified Counselors (NBCC), which develops and implements the first national examination to
certify counselors, the National Counselor Exam (NCE), is formed by APGA.
• 1983—APGA changes its name to the American Association of Counseling and Development (AACD).
• 1984—The Association for Counselors and Educators in Government (ACEG), a division of AACD, is chartered. The division has
since been renamed the Military and Government Counseling Association (MGCA).
• 1985—Chi Sigma Iota, the international honor society for the counseling profession, is founded.
• 1986—The Association for Adult Development and Aging (AADA), a division of AACD, is chartered.
• 1989—The International Association of Marriage and Family Counselors (IAMFC), a division of AACD, is chartered.
• 1991—The American College Counseling Association (ACCA), a division of AACD, is chartered.
• 1993—AACD, formerly known as APGA, changes its name to the American Counseling Association (ACA).
• 1995—ACA makes a major revision to its code of ethics, allowing members and divisions to submit suggestions and ideas and
revising the format of the document to make it more cohesive and organized.
• 1997—The Association for Gay, Lesbian, and Bisexual Issues in Counseling (AGLBIC) is chartered by ACA.
• 2002—Counselors for Social Justice (CSJ), a division of ACA, is chartered.
• 2004—The Association for Creativity in Counseling (ACC), a division of ACA, is established.
• 2005—The ACA code of ethics is revised and includes new sections on technology, end-of-life care, making diagnoses, ending
practice, and choosing therapeutic interventions.
• 2007—The AGLBIC name is changed to the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling
(ALGBTIC).
• 2009—California becomes the final state to offer counselors the option to seek licensure. Also, CACREP publishes revisions to its
accreditation standards.
• 2010–2012—Three legal cases (i.e., Keeton v. Anderson-Wiley, 2011; Ward v Polite, 2012; Ward v. Wilbanks, 2010), involving the
role of value conflicts for counselor trainees working with lesbian, gay, bisexual, transgender, and questioning (LGBTQ) clients, set
the stage for clarifying the role of counselor personal values in the ACA Code of Ethics (2014).
• 2013—The Association for Child and Adolescent Counseling (ACAC), a division of the ACA, is chartered.
• 2014—The seventh and most recent revision of the ACA Code of Ethics is published. This edition includes new or expanded
guidelines to address issues related to technology and social media, distance counseling, multiculturalism and social advocacy,
imposition of personal values, confidentiality, record-keeping, diagnosis, end-of-life care, and selection of counseling interventions
(ACA, 2017a).
• 2017—CACREP and the Council on Rehabilitation Education (CORE) merges. Rehabilitation counseling programs seeking
accreditation now apply through CACREP.
8 Chapter 1 • Professional Orientation and Ethical Practice
section presents an overview of some of the key legal issues
that are crucial for you to be aware of, including the Family
Educational Rights and Privacy Act (FERPA), Individuals with
Disabilities Education Improvement Act (IDEA), U.S. Reha-
bilitation Act of 1973 (Section 504), Health Insurance Porta-
bility and Accountability Act (HIPAA), Patient Protection and
Affordable Care Act of 2010, Mental Health Parity and Addic-
tion Equity Act, and legal considerations related to child abuse
and neglect, counseling minors, and elder abuse.
1.1.2.1 FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT
(FERPA) Enacted in 1974, the Family Educational Rights
and Privacy Act (FERPA), also known as the Buckley Amend-
ment, is a federal law that affects any counselor who works in an
educational setting that receives funding from the U.S. Depart-
ment of Education (USDE, 2015a). Private schools, colleges,
or universities that do not receive any funds from the USDE for
any of their programs do not have to follow this act, but those
institutions represent the minority.
Key Points of FERPA
• FERPA was created to specify the rights of parents (if
the child is a minor) and nonminor students to access and
examine the educational record, petition to have incor-
rect information found in the record amended and ensure
that certain information is not released to outside agencies
without permission.
• An educational record refers to any document or infor-
mation kept by the school relating to a student, such
as attendance, achievement, behavior, activities, and
assessment.
• Parents have the right to access their children’s educa-
tional information until the child is 18 years old or begins
college, whichever comes first, at which point the rights
shift to the student.
• Educational institutions are required to obtain written per-
mission before releasing any information in a student’s
educational record.
• An exception to the preceding rule is that schools have
the ability to give out directory information about stu-
dents without consent. Directory information includes the
student’s name, address, telephone number, date of birth,
place of birth, honors or awards, and dates of attendance at
the school. However, schools must send an annual notice
to students and parents informing them that they have the
right to have their information, or their child’s informa-
tion, barred from release.
• Educational institutions that fail to comply with FERPA
may face punitive action, such as loss of federal funding.
• Professional counselors’ personal notes on students, con-
sidered an expansion of the counselor’s memory that are
kept separate from the educational record in a secure loca-
tion, are considered confidential (Hall & Ratliff, 2017;
Stone, 2013). Students and parents do not have the right
to access counselors’ personal notes. That said, general
counseling case notes may be considered part of a stu-
dent’s educational record, depending on the state.
1.1.2.2 INDIVIDUALS WITH DISABILITIES EDUCATION
IMPROVEMENT ACT (IDEA) Also pertaining to counselors
who work in educational settings, the Individuals with Dis-
abilities Education Improvement Act (IDEA) is a civil rights
law passed to guarantee that students with disabilities receive
the services they need to gain the benefits of education. Like
FERPA, this act applies to any school that receives federal fund-
ing and prohibits educational institutions from putting any stu-
dent at a disadvantage based on a disability. It is important for
professional counselors to be knowledgeable of this act if they
work in an educational institution, because part of their role is
to advocate for the academic needs of their clients.
Key Points of IDEA
• Children are eligible to receive services under IDEA from
birth until the age of 21 years.
• Counselors and educators serve as advocates for children
with special education needs. School counselors are fre-
quently part of the child study team, which evaluates a
child’s educational, psychological, sociological, and med-
ical needs to determine eligibility for services.
• To qualify for eligibility under IDEA, a student must have
a documented disability in at least one of the following
areas: intellectual disability, hearing impairment (includ-
ing deafness), speech or language impairment, visual
impairment (including blindness), serious emotional dis-
turbance, orthopedic impairment, autism, traumatic brain
injury, other health impairment, or specific learning dis-
ability. In addition, the student must need special educa-
tion services as a result of a disability.
• All students with disabilities must be given free appro-
priate public education (FAPE) that addresses their indi-
vidual needs and helps ready them for higher levels of
education or employment.
• Every student who is eligible to receive special education
services under IDEA must have an individualized edu-
cation plan (IEP) on file (USDE, 2007). School systems
convene meetings of multidisciplinary teams to create the
IEP. A student’s IEP delineates what services the student
will receive; when and how often; and goals for the stu-
dent’s learning, which are updated and reviewed yearly.
• It is required that each student’s IEP ensure that the child
receive the benefits of education in the least restrictive
environment (LRE), which was mandated to allow
as many students as possible to remain in regular class-
rooms if their needs could be met there with only limited
accommodation.
• Students covered under IDEA often are also covered
under the more expansive Section 504 of the U.S. Reha-
bilitation Act of 1973.
1.1.2.3 U.S. REHABILITATION ACT OF 1973 (SECTION
504) The U.S. Rehabilitation Act of 1973 (Section 504), a
civil rights act, protects individuals with disabilities from being
discriminated against or denied equal access to services and
opportunities because of their disability—IDEA being one of
those protections. Often, in a school setting, students who do

not qualify for special education services under IDEA may be
eligible for accommodations under Section 504, which has a
more inclusive definition of disability. Unlike IDEA, Section
504 applies not only to educational institutions receiving federal
funds but also to any organization or employer in the United
States receiving federal funds.
Key Points of Section 504
• Eligible individuals must have a physical or psychological
impairment that substantially limits at least one major
life activity. These major life activities include walking,
seeing, hearing, speaking, breathing, working, performing
manual tasks, learning, and caring for oneself (USDOE,
2015b; U.S. Department of Health and Human Services
[USDHHS], 2017a).
• To receive consideration, individuals must also be viewed
as having the disability or have documentation of the dis-
ability, and it must interfere with their ability to meet their
needs.
• In a school setting, when a student indicates a need, a
multidisciplinary team meets to assess the student’s eli-
gibility under Section 504. If the student is eligible, a
504 plan is constructed, which dictates the accommo-
dations or other special considerations the student is
entitled to receive. The team looks at multiple sources
of information when determining students’ eligibility,
including any test scores, grades, educational records,
and medical documentation.
• Although there exists a whole host of possible accommoda-
tions a student may be given, a few examples of accommo-
dations that school personnel make for eligible individuals
include building ramps and installing elevators for students
who are wheelchair-bound or injured, giving students more
time to complete tests or other classroom tasks, and allow-
ing students to use laptop computers to take notes.
1.1.2.4 HEALTH INSURANCE PORTABILITY AND ACCOUNT-
ABILITY ACT (HIPAA) HIPAA is a federal law, passed in 1996,
to protect the privacy of individuals’ medical and mental health
records. Health organizations were to be compliant with this
law by 2003. Under HIPAA, patients are given rights to con-
trol who can view their health records as well as the ability
to inspect their own medical record and request that changes
be incorporated (USDHHS, 2017b). In essence, patients have
a right to control who sees their identifiable health record.
HIPAA applies to doctors, nurses, hospitals, clinics, insurance
companies, health maintenance organizations (HMOs), Medi-
care, Medicaid, mental health professionals, and a variety of
other health care providers. In fact, it would be difficult to find
a health care provider who is not subject to the stipulations out-
lined in HIPAA, so understanding this law is essential to avoid
violating the confidentiality of private client information.
Key Points of HIPAA
• All patients must be given a copy of the HIPAA privacy
policy, which outlines their rights; with whom their pro-
tected health information (PHI)—that is, individually
Chapter 1 • Professional Orientation and Ethical Practice 9
identifiable health information—might be used or shared;
and the procedures for requesting that their information
not be released to certain parties.
• Patients, for their part, are required to sign a document
affirming that they have received information on HIPAA.
• Health organizations must secure all PHI from unautho-
rized individuals and organizations.
• Patients have a right to obtain a copy of their medical
record usually within 30 days.
• Patients have a right to request changes to adjust inac-
curate health information in their record. Should there
be a disagreement by the health organization about
making such changes, the disagreement must be noted
in the file.
• Health organizations are to honor reasonable requests
to contact patients in different locations or by different
methods.
• A counselor following HIPAA must allow clients to view
their records and petition for changes to the counselor’s
notes if they believe any information is false or inaccurate
(USDHHS, 2017b).
1.1.2.5 PATIENT PROTECTION AND AFFORDABLE CARE ACT
OF 2010 The Patient Protection and Affordable Care Act of
2010, commonly referred to as the Affordable Care Act (ACA),
provides health care to Americans and includes consumer pro-
tections from private health insurance companies and limits
long-term health care expenses.
Key Points of the ACA
• The ACA mandates coverage of preventive health ser-
vices such as depression, substance use, and HIV screen-
ings; smoking cessation screenings; obesity screening and
counseling, domestic violence screening and counseling;
and behavioral assessments (ACA, 2012).
• Health insurance companies, with the exception of
grandfathered plans, cannot deny or charge more to indi-
viduals due to a pre-existing health condition (USDHHS,
2017c).
• For insurance plans that cover dependents, children can
be covered under their parent or guardian's plan until the
age of 26 years.
• Lifetime and annual dollar limits on insurance benefits are
not allowed for any insurance policy.
1.1.2.6 MENTAL HEALTH PARITY AND ADDICTION EQUITY
ACT The Mental Health Parity and Addiction Equity Act
(MHPAEA) was signed into law in 2008. It requires insurance
companies offering coverage for mental health and substance
use related services to make that coverage comparable to general
medical coverage.
Key Points of the MHPAEA
• The MHPAEA was developed to protect consumers
directly from large group insurance plans, preventing
annual and lifetime benefit limits for those receiving men-
tal health and/or substance use services.
10 Chapter 1 • Professional Orientation and Ethical Practice
• The ACA augments the protections of the MHPAEA by
identifying mental health and substance use services as
one of the essential health benefits that must be covered
by insurance plans. As such, it indirectly protects consum-
ers who are enrolled in small health plans as well.
1.1.2.7 CHILD ABUSE AND NEGLECT The federal Child
Abuse Prevention and Treatment Act (CAPTA) defines child
abuse and neglect as “Any recent act or failure to act on the part
of a parent or caretaker which results in death, serious physical
or emotional harm, sexual abuse or exploitation; or, an act or
failure to act which presents an imminent risk of serious harm”
(Child Welfare Information Gateway, 2018).
Key Points of CAPTA
• Any counselor who suspects child abuse or neglect is
required by law to report the suspicion to the local child
protective services (CPS) agency within 72 hours from
the time of first awareness of the potentially abusive or
neglectful event (Hall & Ratliff, 2017; Stone, 2013).
Counselors also must submit a written report to CPS after
submitting the initial account.
• Anyone who reports suspected abuse or neglect will not
be held liable, even if CPS fails to find any evidence
supporting the claim during the investigation (Stone,
2013), unless a false report was filed with malicious
intent.
• The ACA Code of Ethics (2014, B.2.a.) upholds this
legal duty, allowing counselors to ethically break confi-
dentiality to protect a client from a potentially dangerous
situation.
1.1.2.8 COUNSELING MINORS When counseling minors,
particularly in a nonschool setting, it is crucial for counselors to
obtain informed consent from the parents or legal guardian and
assent, or agreement, of minors before any counseling begins.
The necessity of informed consent in school systems ordinarily
is dictated by local school or state policies (Hall & Ratliff, 2017;
Stone, 2013).
Key Points of Informed Consent
• During the informed consent and assent process, minors
and their parents must receive details on what they can
expect from counseling, limitations to confidentiality, and
their right to withdraw from treatment at any time (ACA,
2014, A.2.a., A.2.b., & A.2.d.). This information must be
conveyed in a developmentally and culturally sensitive
manner.
• Informed consent should be given in writing to parents
and explained by the counselor to minors in age-appropri-
ate language so that they are able make an educated deci-
sion about whether they want to enter into the counseling
relationship. Some minor children, because of substantial
disability (e.g., intellectual disability) or age, are unable to
give assent for counseling, requiring special precautions
in care and parental consent.
• All counselors should note that although, ethically, the
child (if under the age of 18 years) should be able to expect
confidentiality, parents still retain the legal right to know
what their child discusses in counseling sessions should
they choose to exercise that right. Therefore, counselors
must carefully balance the needs of both parties to most
effectively implement services and must work diligently
to uphold the minor’s ethical rights whenever feasible.
• Some states allow minors of a certain age to consent to
various community health services, including mental
health and substance abuse treatment, without parental
consent. However, these minor consent laws vary among
states, so it is essential to become very familiar with the
laws governing the state where you are practicing or plan
to practice. The Guttmacher Institute (2018) provides a
summary of how minor consent laws are handled by state.
• In a school setting, most professional school counselors
are not required to obtain parental consent before deliver-
ing counseling services to students, although professional
school counselors should familiarize themselves with the
policies of their state and local school boards.
1.1.2.9 ELDER ABUSE Elder abuse typically involves three
different forms of maltreatment toward a vulnerable or inca-
pacitated older adult: physical, sexual, or verbal abuse; financial
exploitation; and neglect of a caregiver to provide proper care.
Estimates of elder abuse frequency typically range from 2% to
10% depending on type, definition, and degree of reporting.
Perpetrators of elder abuse are generally male and can include
family members, paid caregivers, or fellow residents in a care
facility (Dong, 2015; Forman & McBride, 2010).
Key Points of Elder Abuse
• Elder abuse is a criminal offense in all 50 states, with
a majority of states having mandatory reporting laws
(Administration on Aging [AoA], 2017). In cases where
an older adult is neglecting him- or herself in some man-
ner, some states allow law enforcement to intervene when
these individuals refuse services (Forman & McBride,
2010).
• The Older Americans Act was passed in 1965 by Con-
gress to increase social and nutrition services for older
persons and was most recently reauthorized in 2016. Two
specific pieces of this legislation, Title II—Elder Abuse
Prevention and Services and Title VII—Vulnerable Elder
Rights Protection, are particularly salient to the topic of
elder abuse. Collectively, these chapters discuss inclusion
of long-term care ombudsman programs, legal assistance,
greater coordination with law enforcement and court sys-
tems, and greater allotment of funds for detection, assess-
ment, and intervention of elder abuse (AoA, 2017).
• The AoA was developed as part of the Older Americans
Act and oversees major grant programs and other initia-
tives related to this legislation. It is a useful resource for
counselors to be familiar with, particularly for dealing
with elder abuse.

1.1.3 Accreditation and the Council for
Accreditation of Counseling and Related
Educational Programs (CACREP)
Accreditation is a process that eligible educational institutions
and organizations can elect to undergo (i.e., it is voluntary) to
demonstrate that the institution meets set standards. Although
accreditation applies to many careers and professions, for the
purposes of this study guide, we are concerned with educational
accreditation.
• An educational institution seeking accreditation must
apply to the appropriate association. For example, for col-
leges and universities to have their counseling programs
accredited, they apply to the Council for Accreditation
of Counseling and Related Educational Programs
(CACREP), the association in charge of the accredita-
tion for the majority of counseling and counseling-related
programs and undergo its accreditation process.
• The purpose of accreditation for educational institutions
is to signify to the public that the accredited program’s
educators and curriculum adhere to specific standards of
quality; only those institutions that meet the specified cri-
teria become accredited (CACREP, 2016).
• Institutions may seek accreditation for a variety of reasons:
• It increases the institution’s status and prestige.
• It requires institutions to hold themselves accountable
for the quality of their program and educators.
• It encourages colleges and universities to continually
evaluate and assess the effectiveness of their programs
and make changes and improvements as necessary to
ensure adherence to the standards of accreditation.
Educational institutions accredited by CACREP must
undergo and pass the accreditation process every eight
years to retain their certification, so the process of meet-
ing CACREP’s standards is ongoing (CACREP, 2016).
• Students who graduate from an accredited institution
may be more marketable than those students gradu-
ating from an unaccredited institution, because they
have succeeded in meeting specified programmatic
standards. Part of this may result from similarities
between CACREP requirements and state licensure
requirements.
CACREP was established in 1981 to promote excellence
in counseling and counseling-related educational programs.
CACREP has developed and revised educational standards
over the years that institutions must meet to gain the organi-
zation’s accreditation approval. These standards were created
to respond to society’s comprehensive needs, ensuring that
institutions seeking accreditation are providing students with
the necessary tools to address those needs at graduation and
on entrance into the counseling profession (CACREP, 2016).
CACREP accredits master’s-level programs in addic-
tion counseling; career counseling; clinical mental health
counseling; marriage, couple, and family counseling; school
Chapter 1 • Professional Orientation and Ethical Practice 11
counseling; college counseling; and doctoral-level programs in
counselor education and supervision (CACREP, 2016). Cur-
rently, more than 330 universities in the United States have
received CACREP accreditation. In addition, CACREP now
accredits rehabilitation counseling programs since the 2017
merger with CORE.
1.1.4 Advocacy Counseling
Advocacy counseling is concerned with supporting and pro-
moting the needs of clients (e.g., individuals, groups, and com-
munities) and the counseling profession at all levels (local,
state, regional, and national). Examples of advocacy counsel-
ing include teaching clients to self-advocate, being involved
in changes in public policy, writing to or meeting with policy-
makers about bills that affect counselors and clients, or backing
licensure laws. Advocacy counseling also can take many other
forms, such as educating people about the counseling profes-
sion, providing leadership and advocacy training, networking
with the media to have important issues covered, and working
with community organizations to meet the needs of clients.
• Counselors are expected to be advocates not only for
their profession but also for their clients, and to help cli-
ents overcome any barrier that is preventing them from
making progress. The ACA Code of Ethics (2014, A.7.a.)
demands that counselors empower clients to advocate for
themselves when needed or that counselors advocate on
their clients’ behalf (with client consent) when clients
are unable to do so for themselves. ACA has published
“Advocacy Competencies” and the “Multicultural and
Social Justice Counseling Competencies,” which with
counselors should be familiar (see www.counseling.org/
knowledge-center/competencies).
1.1.5 Health Maintenance Organizations (HMO)
A health maintenance organization (HMO), also known as
a managed care organization, is a health care organization that
allows members to access health and mental health services at a
lower cost than many standard health insurance plans. Although
members often pay only a small fee per month, a frequent crit-
icism is that they can visit only hospitals and providers that are
part of their HMO’s network, and often they must receive a
referral from their primary-care physician before visiting any
specialists, including counselors.
• A benefit for mental health providers who are part of an
HMO is that they are given a stable influx of clients and
are ensured payment if they follow the organization’s
regulations. However, a criticism of HMOs is that mental
health providers must give the organization a diagnosis and
detailed history of each client before the HMO will approve
and pay for the treatment, perhaps infringing on the client’s
confidentiality. Mental health professionals also are often
limited in how much time they have to treat clients, and
they are usually required to follow specific guidelines or
treatment modalities in working with their clients.
12 Chapter 1 • Professional Orientation and Ethical Practice
1.1.6 Liability Insurance
In the field of counseling, liability insurance has become a
necessity for all counselors, counseling students, and counselor
educators. In the event that professional counselors find them-
selves in a legal dispute or the subject of a complaint, having
liability insurance can be instrumental in the protection of their
assets and also greatly reduces the financial burden they may
face if found guilty of malpractice or negligence. Many profes-
sional organizations, such as ACA and NBCC, offer reasonably
priced liability insurance to members.
• Although counselors are urged to abide by applicable eth-
ics codes, and doing so will help decrease the likelihood of
negligence or malpractice, there is always inherent risk in
treating clients, and even the best-intentioned profession-
als can make mistakes. Even counselors who are wrongly
accused of negligence or unethical behavior will still have
to respond to the claim, which is costly and can jeopar-
dize their assets (Remley & Herlihy, 2016; Wheeler &
Bertram, 2015).
1.1.7 Licensure
Licensure in the counseling field emerged in the 1970s in an
effort to validate the counseling profession by passing state laws
controlling who could legally practice counseling (Wheeler &
Bertram, 2015). The underlying purpose of state licensure is to
protect the public by ensuring that only qualified profession-
als, granted a license from the state, can legally render certain
counseling services. Just as people must obtain a driver’s license
to legally operate a vehicle, so too must professional counsel-
ors procure a license to practice in most states. Once an indi-
vidual has been licensed, he or she usually is granted the title
of Licensed Professional Counselor (LPC), or a similar title as
determined by a specific state’s law; some examples include
Licensed Clinical Professional Counselor (LCPC), Licensed
Mental Health Counselor (LMHC), and Licensed Clinical Men-
tal Health Counselor (LCMHC).
• Although the requirements for obtaining licensure vary
from state to state, most states require individuals to
achieve at least a master’s degree from an approved insti-
tution (thereby fulfilling specific coursework require-
ments), accrue a certain number of years or hours of
supervised clinical experience, and pass an examination,
such as the NCE.
• Licensure differs from certification: licensure is sanc-
tioned and regulated by a state or territory. As such, the
state dictates professional requirements for counselors and
restricts who can use or practice with that professional
counselor title. Certification is determined by a particular
trade and thus is not governed by a state.
• Virginia was the first state to license professional coun-
selors (in 1976). All 50 states have licensure laws, as do
the District of Columbia, Guam, and Puerto Rico (Amer-
ican Association of State Counseling Boards [AASCB],
2019a).
• Although professional counselors can secure national
certification, to enhance their professional credibility,
through the NBCC, currently there is no nationally rec-
ognized licensure. Licensure portability would establish
reciprocity for licensed counselors. This would allow a
counselor who is licensed in one state to work in another
state without having to reapply for licensure or fulfill
additional requirements.
• In 2017, representatives of the AASCB, the Association
for Counselor Education and Supervision, the American
Mental Health Counselors Association (AMHCA), and
the National Board of Certified Counselors (NBCC)
served on a portability task force to recommend the mini-
mum licensure requirements needed to allow for licensure
portability. These recommendations are referred to as the
National Counselor Licensure Endorsement Process. The
process would allow any counselor currently licensed
at the highest level of licensure of independent practice
within his or her state to also be licensed in any other
state or territory, provided that he or she (a) has engaged
in ethical practice with no disciplinary sanctions within
the previous five years; (b) has possessed the license for at
least three years; (c) has completed a comprehensive exam
if required by the state regulatory body; and (d) meets
all supervised experienced standards of the state, holds
the National Certified Counselor (NCC) credential, in
good standing, from the NBCC, or holds a graduate-level
degree from a CACREP-accredited program (AMHCA,
2019).
1.1.8 The National Board for Certified
Counselors
The National Board for Certified Counselors (NBCC) is the
chief credentialing organization in the United States for pro-
fessional counselors seeking certification. Founded in 1982
as the result of an ACA committee recommendation, NBCC
is a nonprofit organization that certifies counselors who have
met its criteria for education and training and have passed the
National Counselor Examination (NCE), which it developed
and administers. The mission of NBCC is to promote and rec-
ognize counselors who meet established standards of quality in
delivering counseling services.
• Certification with NBCC is voluntary, but counselors who
obtain certification strengthen their professional reputa-
tion. In some cases, the certification has made counselors
eligible for salary increases.
• NBCC offers counselors general and specialty credential-
ing options (NBCC, 2017). NBCC’s premier credential
is the National Certified Counselor (NCC). Specialties
within this credential are the National Certified School
Counselor (NCSC), the Certified Clinical Mental Health
Counselor (CCMHC), and the Master Addictions Coun-
selor (MAC). Candidates must first attain the NCC before
they can earn a specialty credential; in some cases, though,
they may apply concurrently for both the general and a

specialty credential. Acquiring a specialty credential pro-
vides counselors with greater notoriety within the coun-
seling community and can increase financial remuneration
or professional opportunities.
• The Center for Credentialing and Education (CCE),
an affiliate of NBCC, offers the Approved Clinical
Supervisor (ACS) credential to promote the profes-
sional identity and accountability of clinical supervi-
sors (CCE, 2019).
• The NCC is NBCC’s general-practice credential. To be
eligible for the NCC, the candidate must meet one of
the following educational requirements: (1) be a current
student in a counseling program that participates in the
Graduate Student Application process; (2) have earned
at least a master’s degree from a CACREP-accredited
program; (3) have earned at least a master’s degree in a
counseling field and have taken courses in the following
areas: human growth and development, social/cultural
foundations, helping relationships, group work, career
and lifestyle development, assessment, research and pro-
gram evaluation, and professional orientation and ethical
practice, and have been employed in the counseling pro-
fession under supervision for two or more years; or (4)
hold a counseling license conferred by the candidate’s
state board and possess at least a master’s degree in a
mental health field.
1.1.9 Practice Multiple-Choice Items:
Introduction to Professional Orientation and
Ethical Practices
1. The American Counseling Association was originally
named
a. American Association of Counseling and Development.
b. American Personnel and Guidance Association.
c. National Vocational Guidance Association.
d. American Counseling Association.
2. When working with an 8-year-old child in a nonschool
setting, it is commonly necessary to obtain
a. assent from the child and informed consent from the
parent.
b. informed consent from only the child.
c. informed consent from only the parent.
d. informed consent from both the child and the parent.
3. The Buckley Amendment is also known as the
a. Health Insurance Portability and Accountability Act.
b. Section 504 of the U.S. Rehabilitation Act.
c. Individuals with Disabilities Education Improvement
Act.
d. Family Educational Rights and Privacy Act.
4. When a client discloses that she has been a victim of elder
abuse, counselors
a. should refer to consent laws within their particular state.
b. are encouraged to contact protective services
immediately.
Chapter 1 • Professional Orientation and Ethical Practice 13
c. are commonly mandated to report to law enforcement.
d. should review guidelines set forth by HIPAA.
5. Each of the following statements is correct EXCEPT
a. licensure was created to protect the public.
b. counselors who hold a license from one state have rec-
iprocity in every other state.
c. Virginia was the first state to license counselors.
d. the requirements for acquiring licensure vary from
state to state.
Self-Check 1.1
Take an automatically-graded version of this self-check quiz.
1.2 COUNSELING SPECIALIZATIONS
The counseling profession contains a number of specializations,
each of which is dedicated to addressing the needs of a particular
group of people. Each specialization requires counselors to meet
its specific training requirements, and all are driven by the same
overarching mission to promote the growth and potential of all
individuals.
A professional counselor works in diverse settings
with diverse clientele, including colleges, hospitals, clin-
ics, private practices, and schools. Many of the counselors
from special counseling disciplines are described in the sec-
tions that follow. Other types of professional counselors not
described here include career and substance abuse counsel-
ors. These specialty areas are described in other chapters of
this study guide within a more specific context. Regardless
of the specialization within counseling, all professional coun-
selors are concerned with working not only to treat but also
to prevent psychological problems, and to promote healthy
human development through all stages of life. Professional
counselors often work with clients to overcome developmen-
tal and unexpected life changes, come to terms with their
environment, adjust to foreign situations, and find ways to
improve the quality of clients’ lives.
If properly trained in administration of psychological tests,
professional counselors are eligible in most states to administer
such tests as part of their practice. As previously mentioned,
to become a professional counselor, individuals must earn at
least a master’s degree in the field of counseling. This second
section of Chapter 1 outlines the predominant counseling and
related specializations currently in existence, specifically clin-
ical mental health counseling, college admissions counseling,
college counseling, rehabilitation counseling, school counseling,
and other types of mental health counseling.
1.2.1 Clinical Mental Health Counseling
Mental health counselors first surfaced in the 1940s and 1950s
but did not benefit from formal training or employment in sig-
nificant numbers until the passing of the Community Mental
Health Act of 1963, which provided funding for the establish-
ment of mental health centers across the United States to provide
greater access to mental health care services.
14 Chapter 1 • Professional Orientation and Ethical Practice
• Clinical mental health counselors work with individuals,
groups, and families in many different settings, includ-
ing community organizations, hospitals, drug and alcohol
treatment centers, and private practices.
• Mental health counselors are trained in assessment; diag-
nosis; treatment planning; psychotherapy; substance abuse
treatment, prevention, and intervention; crisis counseling;
and brief therapy (American Mental Health Counselors
Association [AMHCA], 2017).
• To become licensed as a mental health counselor, indi-
viduals must earn a master’s degree in a counseling
field, pass their state’s required examination, and have
at least two years of work experience under supervision
(AMHCA, 2017).
• Many mental health counselors work toward the NCC cre-
dential and the CCMHC specialty credential, both granted
by NBCC, to forward their careers, become eligible pro-
viders for certain insurance companies, or strengthen their
professional reputation.
• AMHCA is the division of ACA that serves as the profes-
sional association for mental health counselors.
1.2.2 College Admissions Counseling
College admissions counseling focuses on helping students
maneuver through the college admissions process to select and,
ideally, to secure entry into suitable postsecondary educational
institutions.
• College admissions counselors work in a variety of set-
tings, most commonly in colleges, universities, and high
schools. Often, professional school counselors who
work in high schools are highly involved in this process,
although some high schools employ a separate counselor
whose sole responsibility is to work with students inter-
ested in attending college; these individuals are usually
called college counselors, but the role is relegated to
college admissions counseling—not to the wellness and
mental health roles of the college counselors discussed
in the next section. Educational consultants are people
who work outside the school district and provide college
counseling services to students for a fee (National Asso-
ciation for College Admission Counseling, 2015). Finally,
some areas have commercial college counseling centers
that offer students a variety of services ranging from test
preparation classes to assistance with college applications.
• The bulk of college admissions counseling occurs at the
secondary level, particularly in students’ junior and senior
years, although some schools believe it is useful to inte-
grate college counseling programs into the middle school
curricula as well.
• Counselors at the high school and college levels assist
students in the college admissions process through aca-
demic advising, during which they help students choose
high school courses beneficial to their postsecondary aspi-
rations and often administer interest assessments, which
facilitate students’ personal exploration of career options
in concert with their interests. College admissions coun-
selors also work with students individually to discuss spe-
cific college options, and they work with groups to guide
students in preparing to complete college applications,
take the Scholastic Achievement Test (SAT) or American
College Testing (ACT) examinations, and obtain financial
aid, if necessary.
• The National Association for College Admission
Counseling (NACAC) is the professional association for
individuals who work in this specialization. NACAC is
not affiliated with ACA.
1.2.3 College Counseling
The previous section provided an overview of college admis-
sion counseling primarily at the secondary level. College coun-
seling at the postsecondary level has a much different charter,
and counselors who work in this specialty have a distinct job
description. Although college admissions counselors are con-
cerned with helping students apply and gain admittance to post-
secondary schools, college counselors in higher education work
in counseling centers on college campuses to support students
who have mental health and educational concerns that are neg-
atively affecting their personal, social, and academic endeavors.
• Individuals working in college counseling centers are often
professional counselors and psychologists who hold doc-
toral degrees; they may also be counseling interns. College
counselors engage in individual and group counseling and
serve as liaisons to community services and resources. Most
college counseling services are free to students.
• College counselors help students deal with diverse issues,
including homesickness, social problems, relationship
issues, academic problems, stress, eating disorders, and
mental illnesses. Because of the variety of issues pre-
sented to college counselors, most are trained in crisis
counseling, diagnosis, and treatment planning.
• The American College Counseling Association, a division
of ACA, is the professional association for counselors
working in higher education.
1.2.4 Rehabilitation Counseling
A certified rehabilitation counselor (CRC) seeks to help indi-
viduals with disabilities work through personal and vocational
issues they may encounter as a result of their impairment. CRC
clients have wide-ranging disabilities. Some are a result of ill-
ness, although others are due to accidents, birth defects, or many
other causes.
• CRCs are employed in a wide range of settings, such
as public vocational rehabilitation agencies, hospitals,
community centers, schools, and employee assistance
programs.
• After conducting a thorough assessment of the client and
gathering information on the client’s condition and job
skills from a variety of sources, CRCs begin to work with
the client to improve the quality of the client’s life and help
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 Bathe the eye frequently with warm milk and water, and apply,
every night at bedtime, a warm white-bread poultice.
No medicine is required; but if the child be gross, keep him for a
few days from meat, and let him live on bread and milk and
farinaceous puddings.
243. If a child have large bowels, what would you recommend as
likely to reduce their size?
It ought to be borne in mind that the bowels of a child are larger in
proportion than those of an adult. But, if they be actually larger than
they ought to be, let them be well rubbed for a quarter of an hour at a
time night and morning, with soap liniment, and then apply a broad
flannel belt. “A broad flannel belt worn night and day, firm but not
tight, is very serviceable.”[244] The child ought to be prevented from
drinking as much as he has been in the habit of doing; let him be
encouraged to exercise himself well in the open air; and let strict
regard be paid to his diet.
244. What are the best aperients for a child?
If it be actually necessary to give him opening medicine, one or
two teaspoonfuls of syrup of senna, repeated if necessary, in four
hours, will generally answer the purpose; or, for a change, one or two
teaspoonfuls of castor oil may be substituted. Lenitive electuary
(compound confection of senna) is another excellent aperient for the
young, it being mild in its operation, and pleasant to take; a child
fancying it is nothing more than jam, and which it much resembles
both in appearance and in taste. The dose is half or one teaspoonful
early in the morning occasionally. Senna is an admirable aperient for
a child, and is a safe one, which is more than can be said of many
others. It is worthy of note that “the taste of senna may be concealed
by sweetening the infusion,[245] adding milk, and drinking as ordinary
tea, which, when thus prepared, it much resembles.”[246] Honey, too,
is a nice aperient for a child—a teaspoonful ought to be given either
by itself, or spread on a slice of bread.
Some mothers are in the habit of giving their children jalap
gingerbread. I do not approve of it, as jalap is a drastic griping
purgative; besides, jalap is very nasty to take—nothing will make it
palatable.
 Fluid magnesia—solution of the bicarbonate of magnesia—is a
good aperient for a child; and, as it has very little taste, is readily
given, more especially if made palatable by the addition either of a
little syrup or of brown sugar. The advantages which it has over the
old solid form are, that it is colorless and nearly tasteless, and never
forms concretions in the bowels, as the solid magnesia, if persevered
in for any length of time, sometimes does. A child two or three years
old may take one or two tablespoonfuls of the fluid, either by itself or
in his food, repeating it every four hours until the bowels be opened.
When the child is old enough to drink the draught off immediately,
the addition of one or two teaspoonfuls of lemon-juice, to each dose
of the fluid magnesia, makes a pleasant effervescing draught, and
increases its efficacy as an aperient.
Bran-bread[247] and treacle will frequently open the bowels; and as
treacle is wholesome, it may be substituted for butter when the
bowels are inclined to be costive. A roasted apple, eaten with raw
sugar, is another excellent mild aperient for a child. Milk gruel—that
is to say, milk thickened with oatmeal—forms an excellent food for
him, and often keeps his bowels regular, and thus (which is a very
important consideration) supersedes the necessity of giving him an
aperient. An orange (taking care he does not eat the peel or the pulp),
or a fig after dinner, or a few Muscatel raisins, will frequently
regulate the bowels.
Stewed prunes is another admirable remedy for the costiveness of
a child. The manner of stewing them is as follows: Put a pound of
prunes in a brown jar, add two tablespoonfuls of raw sugar, then
cover the prunes and the sugar with cold water; place them in the
oven, and let them stew for four hours. A child should every morning
eat half a dozen or a dozen of them, until the bowels be relieved,
taking care that he does not swallow the stones.
A suppository is a mild and ready way of opening the bowels of a
child. When he is two or three years old and upwards, a candle
suppository is better than a soap suppository. The way of preparing
it is as follows: Cut a piece of dip-tallow candle—the length of three
inches—and insert it as you would a clyster pipe, about two inches up
the fundament, allowing the remaining inch to be in sight, and there
let the suppository remain until the bowels be opened.
 245. What are the most frequent causes of Protrusion of the lower
bowel?
The too common and reprehensible practice of a parent
administering frequent aperients, especially calomel and jalap, to her
child. Another cause, is allowing him to remain for a quarter of an
hour or more at a time on his chair; this induces him to strain, and to
force the gut down.
246. What are the remedies?
If the protrusion of the bowel have been brought on by the abuse
of aperients, abstain for the future from giving them; but if medicine
be absolutely required, give the mildest—such as either syrup of
senna or castor oil—and the less of those the better.
If the external application of a purgative will have the desired
effect, it will, in such cases, be better than the internal
administration of aperients. Dr. Merriman’s Purgative Liniment[248]
is a good one for the purpose. Let the bowels be well rubbed every
night and morning, for five minutes at a time, with the liniment.
A wet compress to the bowels will frequently open them, and will
thus do away with the necessity of giving an aperient—a most
important consideration. Fold a napkin in six thicknesses, soak it in
cold water, and apply it to the bowels, over which put either a thin
covering or sheet of gutta-percha, or a piece of oiled silk; keep it in its
place with a broad flannel roller, and let it remain on the bowels for
three or four hours, or until they be opened.
Try what diet will do, as opening the bowels by a regulated diet is
far preferable to the giving of aperients. Let him have either bran-
bread, Robinson’s Patent Groats made into gruel with new milk, or
Du Barry’s Arabica Revalenta, or a slice of Huntley and Palmer’s
lump gingerbread. Let him eat stewed prunes, stewed rhubarb,
roasted apples, strawberries, raspberries, the inside of grapes and
gooseberries, figs, etc. Give him early every morning a draught of
cold water.
Let me, again, urge you not to give aperients in these cases, or in
any case, unless you are absolutely compelled. By following my
advice you will save yourself an immense deal of trouble, and your
child a long catalogue of misery. Again, I say, look well into the
matter, and whenever it be practicable, avoid purgatives.
 Now, with regard to the best manner of returning the bowel, lay
the child upon the bed on his face and bowels, with his hips a little
raised; then smear lard on the forefinger of your right hand (taking
care that the nail be cut close) and gently with your forefinger press
the bowel into its proper place.
Remember, if the above methods be observed, you cannot do the
slightest injury to the bowel, and the sooner it be returned the better
it will be for the child; for, if the bowel be allowed to remain long
down, it may slough or mortify, and death may ensue. The nurse,
every time he has a motion, must see that the bowel does not come
down, and if it does, she ought instantly to return it. Moreover, the
nurse should be careful not to allow the child to remain on his chair
more than two or three minutes at a time.
Another excellent remedy for the protrusion of the lower bowel is
to use every morning a cold salt and water sitz-bath. There need not
be more than a depth of three inches of water in the bath; a small
handful of table salt should be dissolved in the water; a dash of warm
water in the winter time must be added to take off the extreme chill,
and the child ought not to be allowed to sit in the bath for more than
one minute, or while the mother can count a hundred, taking care
the while to throw either a square of flannel or a small shawl over his
shoulders. The sitz-bath ought to be continued for months, or until
the complaint be removed. I cannot speak in too high praise of these
baths.
247. Do you advise me, every spring and fall, to give my child
brimstone to purify and sweeten his blood, and as a preventive
medicine?
Certainly not: if you wish to take away his appetite and to weaken
and depress him, give him brimstone! Brimstone is not a remedy fit
for a child’s stomach. The principal use and value of brimstone is as
an external application in itch, and as an internal remedy, mixed
with other laxatives, in piles—piles being a complaint of adults. In
olden times poor unfortunate children were dosed every spring and
fall with brimstone and treacle, to sweeten their blood! Fortunately
for the present race, there is not so much of that folly practiced, but
still there is room for improvement.
To dose a healthy child with physic is the grossest absurdity. No,
the less physic a delicate child has the better it will be for him, but
physic to a healthy child is downright poison!—and brimstone of all
medicines! It is both weakening and depressing to the system, and by
opening the pores of the skin and by relaxing the bowels, is likely to
give cold, and thus to make a healthy a sickly child. Sweeten his
blood! It is more likely to weaken his blood, and thus to make his
blood impure! Blood is not made pure by drugs, but by Nature’s
medicine: by exercise, by pure air, by wholesome diet, by sleep in a
well-ventilated apartment, by regular and thorough ablution.
Brimstone a preventive medicine? Preventive medicine—and
brimstone especially in the guise of a preventive medicine—is “a
mockery, a delusion, and a snare.”
248. When a child is delicate, and his body, without any
assignable cause is gradually wasting away, and the stomach
rejects all food that is taken, what plan can be adopted likely to
support his strength, and thus, probably, be the means of saving his
life?
I have seen, in such a case, great benefit to arise from half a
teacupful of either strong mutton broth, or of strong beef-tea, used as
an enema, every four hours.[249]
It should be administered slowly, in order that it may remain in
the bowel. If the child be sinking, either a dessertspoonful of brandy,
or half a wineglassful of port wine ought to be added to each enema.
The above plan ought only to be adopted if there be no diarrhœa. If
there be diarrhœa, an enema must not be used. Then, provided there
be great wasting away, and extreme exhaustion, and other remedies
having failed, it would be advisable to give, by the mouth, raw beef
of the finest quality, which ought to be taken from the hip-bone, and
should be shredded very fine. All fat and skin must be carefully
removed. One or two teaspoonfuls (according to the age of the child)
ought to be given every four hours. The giving of raw meat to
children in exhaustive diseases, such as excessive long-standing
diarrhœa, was introduced into practice by a Russian physician, a
Professor Weisse, of St. Petersburg. It certainly is, in these cases, a
most valuable remedy, and has frequently been the means of
snatching such patients from the jaws of death. Children usually take
raw meat with avidity and with a relish.
249. If a child be naturally delicate, what plan would you
recommend to strengthen him?
 I should advise strict attention to the rules above mentioned, and
change of air—more especially, if it be possible, to the coast. Change
of air, sometimes, upon a delicate child, acts like magic, and may
restore him to health when all other means have failed. If a girl be
delicate, “carry her off to the farm, there to undergo the discipline of
new milk, brown bread, early hours, no lessons, and romps in the
hay-field.”[250] This advice is, of course, equally applicable for a
delicate boy, as delicate boys and delicate girls ought to be treated
alike. Unfortunately, in these very enlightened days! there is too
great a distinction made in the respective management and
treatment of boys and girls.
The best medicines for a delicate child will be the wine of iron and
cod-liver oil. Give them combined in the manner I shall advise when
speaking of the treatment of Rickets.
In diseases of long standing, and that resist the usual remedies,
there is nothing like change of air. Hippocrates, the father of
medicine, says:
“In longis morbis solum mutare.”
(In tedious diseases to change the place of residence.)

A child who, in the winter, is always catching cold, whose life

during half of the year is one continued catarrh, who is in
consequence likely, if he grow up at all, to grow up a confirmed
invalid, ought, during the winter months, to seek another clime; and
if the parents can afford the expense, they should, at the beginning of
October, cause him to bend his steps to the south of Europe—
Mentone being as good a place as they could probably fix upon.
250. Do you approve of sea bathing for a delicate young child?
No: he is frequently so frightened by it that the alarm would do
him more harm than the bathing would do him good. The better plan
would be to have him every morning well sponged, especially his
back and loins, with sea water; and to have him as much as possible
carried on the beach, in order that he may inhale the sea breezes.
When he be older, and is not frightened at being dipped, sea
bathing will be very beneficial to him. If bathing is to do good, either
to an adult or to a child, it must be anticipated with pleasure, and
neither with dread nor with distaste.
 251. What is the best method of administering medicine to a
child?
If he be old enough, appeal to his reason; for, if a mother endeavor
to deceive her child, and he detect her, he will for the future suspect
her.
If he be too young to be reasoned with, then, if he will not take his
medicine, he must be compelled. Lay him across your knees, let both
his hands and his nose be tightly held, and then, by means of the
patent medicine-spoon, or, if that be not at hand, by either a tea or a
dessertspoon, pour the medicine down his throat, and he will be
obliged to swallow it.
It may be said that this is a cruel procedure; but it is the only way
to compel an unruly child to take physic, and is much less cruel than
running the risk of his dying from the medicine not having been
administered.[251]
252. Ought a sick child to be roused from his sleep to give him
physic, when it is time for him to take it?
On no account, as sleep, being a natural restorative, must not be
interfered with. A mother cannot be too particular in administering
the medicine, at stated periods, while he is awake.
253. Have you any remarks to make on the management of a
sick-room, and have you any directions to give on the nursing of a
sick child?
In sickness select a large and lofty room; if in the town, the back of
the house will be preferable—in order to keep the patient free from
noise and bustle—as a sick-chamber cannot be kept too quiet. Be
sure that there be a chimney in the room—as there ought to be in
every room in the house—and that it be not stopped, as it will help to
carry off the impure air of the apartment. Keep the chamber well
ventilated, by, from time to time, opening the window. The air of the
apartment cannot be too pure; therefore, let the evacuations from the
bowels be instantly removed, either to a distant part of the house, or
to an out-house, or to the cellar, as it might be necessary to keep
them for the medical man’s inspection.
Let there be a frequent change of linen, as in sickness it is even
more necessary than in health, more especially if the complaint be
fever. In an attack of fever clean sheets ought, every other day, to be
put on the bed; clean body-linen every day. A frequent change of
linen in sickness is most refreshing.
If the complaint be fever, a fire in the grate will not be necessary.
Should it be a case either of inflammation of the lungs or of the chest,
a small fire in the winter time is desirable, keeping the temperature
of the room as nearly as possible at 60° Fahrenheit. Bear in mind
that a large fire in a sick-room cannot be too strongly condemned;
for if there be fever—and there are scarcely any complaints without—
a large fire only increases it. Small fires, in cases either of
inflammation of the lungs or of the chest, in the winter time,
encourage ventilation of the apartment, and thus carry off impure
air. If it be summer time of course fires would be improper. A
thermometer is an indispensable requisite in a sick-room.
In fever, free and thorough ventilation is of vital importance, more
especially in scarlet fever; then a patient cannot have too much air; in
scarlet fever, for the first few days the windows, be it winter or
summer, must to the widest extent be opened. The fear of the patient
catching cold by doing so is one of the numerous prejudices and
baseless fears that haunt the nursery, and the sooner it is exploded
the better it will be for human life. The valances and bed-curtains
ought to be removed, and there should be as little furniture in the
room as possible.
If it be a case of measles, it will be necessary to adopt a different
course; then the windows ought not to be opened, but the door must
from time to time be left ajar. In a case of measles, if it be winter
time, a small fire in the room will be necessary. In inflammation of
the lungs or of the chest, the windows should not be opened, but the
door ought occasionally to be left unfastened, in order to change the
air and to make it pure. Remember, then, that ventilation, either by
open window or by open door, is most necessary in all diseases.
Ventilation is one of the best friends a doctor has.
In fever, do not load the bed with clothes; in the summer a sheet is
sufficient, in the winter a sheet and a blanket.
In fever, do not be afraid of allowing the patient plenty either of
cold water or of cold toast and water; Nature will tell him when he
has had enough. In measles, let the chill be taken off the toast and
water.
 In croup, have always ready a plentiful supply of hot water, in case
a warm bath might be required.
In child-crowing, have always in the sick-room a supply of cold
water, ready at a moments notice to dash upon the face.
In fever, do not let the little patient lie on the lap; he will rest more
comfortably on a horse-hair mattress in his crib or cot. If he have
pain in the bowels, the lap is most agreeable to him: the warmth of
the body, either of the mother or of the nurse, soothes him; besides,
if he be on the lap, he can be turned on his stomach and on his
bowels, which often affords him great relief and comfort. If he be
much emaciated, when he is nursed, place a pillow upon the lap and
let him lie upon it.
In head affections, darken the room with a green calico blind;
keep the chamber more than usually quiet; let what little talking is
necessary be carried on in whispers, but the less of that the better;
and in head affections, never allow smelling-salts to be applied to the
nose, as they only increase the flow of blood to the head, and
consequently do harm.
It is often a good sign when a child, who is seriously ill, suddenly
becomes cross. It is then he begins to feel his weakness, and to give
vent to his feelings. “Children are almost always cross when
recovering from an illness, however patient they may have been
during its severest moments, and the phenomenon is not by any
means confined to children.”[252]
A sick child must not be stuffed with much food at a time. He will
take either a tablespoonful of new milk or a tablespoonful of chicken-
broth every half hour, with greater advantage than a teacupful of
either the one or the other every four hours, which large quantity
would very probably be rejected from his stomach, and may cause
the unfortunately treated child to die of starvation!
If a sick child be peevish, attract his attention either by a toy or by
an ornament; if he be cross, win him over to good humor by love,
affection, and caresses, but let it be done gently and without noise.
Do not let visitors see him; they will only excite, distract, and irritate
him, and help to consume the oxygen of the atmosphere, and thus
rob the air of its exhilarating health-giving qualities and purity; a
sick-room, therefore, is not a proper place either for visitors or for
gossips.
In selecting a sick-nurse, let her be gentle, patient, cheerful, quiet,
and kind, but firm withal; she ought to be neither old nor young; if
she be old, she is often garrulous and prejudiced, and thinks too
much of her trouble; if she be young, she is frequently thoughtless
and noisy; therefore choose a middle-aged woman. Do not let there
be in the sick-room more than, besides the mother, one efficient
nurse; a great number can be of no service—they will only be in each
other’s way, and will distract the patient.
Let stillness, especially if the head be the part affected, reign in a
sick-room. Creaking shoes[253] and rustling silk dresses ought not to
be worn in sick-chambers—they are quite out of place there. If the
child be asleep, or if he be dozing, perfect stillness must be enjoined
—not even a whisper should be heard:
“In the sick-room be calm,
Move gently and with care,
Lest any jar or sudden noise
Come sharply unaware.

You cannot tell the harm,

The mischief it may bring,
To wake the sick one suddenly,
Besides the suffering.

The broken sleep excites

Fresh pain, increased distress;
The quiet slumber undisturb’d
Soothes pain and restlessness.

Sleep is the gift of God:

Oh! bear these words at heart,—
‘He giveth his beloved sleep,’
And gently do thy part.”[254]

If there be other children, let them be removed to a distant part of

the house; or, if the disease be of an infectious nature, let them be
sent away from home altogether.
In all illnesses—and bear in mind the following is most important
advice—a child must be encouraged to try and make water, whether
he ask or not, at least four times during the twenty-four hours; and at
any other time, if be expresses the slightest inclination to do so. I
have known a little fellow to hold his water, to his great detriment,
for twelve hours, because either the mother had in her trouble
forgotten to inquire, or the child himself was either too ill or too
indolent to make the attempt.
See that the medical man’s directions are, to the very letter, carried
out. Do not fancy that you know better than he does, otherwise you
have no business to employ him. Let him, then, have your implicit
confidence and your exact obedience. What you may consider to be a
trifling matter, may frequently be of the utmost importance, and may
sometimes decide whether the case shall either end in life or death!
Lice.—It is not very poetical, as many of the grim facts of everyday
life are not, but, unlike a great deal of poetry, it is unfortunately too
true that after a severe and dangerous illness, especially after a bad
attack of fever, a child’s head frequently becomes infested with
vermin—with lice! It therefore behooves a mother herself to
thoroughly examine, by means of a fine-tooth comb,[255] her child’s
head, in order to satisfy her mind that there be no vermin there. As
soon as he be well enough, he ought to resume his regular ablutions
—that is to say, that he must go again regularly into his tub, and have
his head every morning thoroughly washed with soap and water. A
mother ought to be particular in seeing that the nurse washes the
hairbrush at least once every week; if she does not do so, the dirty
brush which had, during the illness, been used, might contain the
“nits,”—the eggs of the lice,—and would thus propagate the vermin,
as they will, when on the head of the child, soon hatch. If there be
already lice on the head, in addition to the regular washing every
morning with the soap and water, and after the head has been
thoroughly dried, let the hair be well and plentifully dressed with
camphorated oil—the oil being allowed to remain on until the next
washing on the following morning. Lice cannot live in oil (more
especially if, as in camphorated oil, camphor be dissolved in it), and
as the camphorated oil will not, in the slightest degree, injure the
hair, it is the best application that can be used. But as soon as the
vermin have disappeared, let the oil be discontinued, as the natural
oil of the hair is, at other times, the only oil that is required on the
head.
 The “nit”—the egg of the louse—might be distinguished from scurf
(although to the naked eye it is very much like it in appearance) by
the former fastening firmly on one of the hairs as a barnacle would
on a rock, and by it not being readily brushed off as scurf would,
which latter (scurf) is always loose.
254. My child, in the summer time, is much tormented with fleas:
what are the best remedies?
A small muslin bag, filled with camphor, placed in the cot or bed,
will drive fleas away. Each flea-bite should, from time to time, be
dressed by means of a camel’s-hair brush, with a drop or two of spirit
of camphor, an ounce bottle of which ought, for the purpose, to be
procured from a chemist. Camphor is also an excellent remedy to
prevent bugs from biting. Bugs and fleas have a horror of camphor;
and well they might, for it is death to them!
There is a famous remedy for the destruction of fleas
manufactured in France, entitled “La Poudre Insecticide,” which,
although perfectly harmless to the human economy, is utterly
destructive to fleas. Bugs are best destroyed by oil of turpentine; the
places they do love to congregate in should be well saturated, by
means of a brush, with the oil of turpentine. A few dressings will
effectually destroy both them and their young ones.
255. Suppose a child to have had an attack either of inflammation
of the lungs or of bronchitis, and to be much predisposed to a
return: what precautions would you take to prevent either the one
or the other for the future?
I would recommend him to wear fine flannel instead of lawn
shirts; to wear good lamb’s-wool stockings above the knees, and
good, strong, dry shoes to his feet; to live, weather permitting, a great
part of every day in the open air; to strengthen his system by good
nourishing food—by an abundance of both milk and meat (the
former especially); to send him, in the autumn, for a couple of
months, to the sea-side; to administer to him, from time to time,
cod-liver oil; in short, to think only of his health, and to let learning,
until he be stronger, be left alone.
I also advise either table salt or bay salt to be added to the water in
which the child is washed with in the morning, in a similar manner
as recommended in answer to the 123d question.
 256. Then do you not advise such a child to be confined within
doors?
If any inflammation be present, or if he have but just recovered
from one, it would be improper to send him into the open air, but not
otherwise, as the fresh air would be a likely means of strengthening
the lungs, and thereby of preventing an attack of inflammation for
the future. Besides, the more a child is coddled within doors, the
more likely will he be to catch cold, and to renew the inflammation.
If the weather be cold, yet neither wet nor damp, he ought to be sent
out, but let him be well clothed; and the nurse should have strict
injunctions not to stand about entries, or in any draughts—indeed,
not to stand about at all, but to keep walking about all the time she is
in the open air. Unless you have a trustworthy nurse, it will be well
for you either to accompany her in her walk with your child, or
merely to allow her to walk with him in the garden, as you can then
keep your eye upon both of them.
257. If a child be either chicken-breasted, or if he be narrow-
chested, are there any means of expanding and of strengthening his
chest?
Learning ought to be put out of the question; attention must be
paid to his health alone, or consumption will probably mark him as
its own! Let him live as much as possible in the open air; if it be
country, so much the better. Let him rise early in the morning, and
let him go to bed betimes; and if he be old enough to use the dumb-
bells, or, what is better, an india-rubber chest expander, he should
do so daily. He ought also to be encouraged to use two short sticks,
similar to, but heavier than, a policeman’s staff, and to go, every
morning, through regular exercises with them. As soon as he be old
enough, let him have lessons from a drill-sergeant and from a
dancing-master. Let him be made both to walk and to sit upright,
and let him be kept as much as possible upon a milk diet,[256] and
give him as much as he can eat of fresh meat every day. Cod-liver oil,
a teaspoonful or a dessertspoonful, according to his age, twice a day,
is serviceable in these cases. Stimulants ought to be carefully
avoided. In short, let every means be used to nourish, to strengthen,
and invigorate the system, without at the same time creating fever.
Such a child should be a child of nature; he ought almost to live in
the open air, and throw his books to the winds. Of what use is
learning without health? In such a case as this you cannot have both.
258. If a child be round-shouldered, or if either of his shoulder-
blades have “grown out,” what had better be done?
Many children have either round shoulders, or have their
shoulder-blades grown out, or have their spines twisted, from
growing too fast, from being allowed to slouch in their gait, and from
not having sufficient nourishing food, such as meat and milk, to
support them while the rapid growth of childhood is going on.
If your child be affected as above described, nourish him well on
milk and on farinaceous food, and on meat once a day, but let milk
be his staple diet; he ought, during the twenty-four hours, to take two
or three pints of new milk. He should almost live in the open air, and
must have plenty of play. If you can so contrive it, let him live in the
country. When tired, let him lie, for half an hour, two or three times
daily, flat on his back on the carpet. Let him rest at night on a horse-
hair mattress, and not on a feather bed.
Let him have every morning, if it be summer, a thorough cold
water ablution; if it be winter, let the water be made tepid. Let either
two handfuls of table salt or a handful of bay salt be dissolved in the
water. Let the salt and water stream well over his shoulders and
down his back and loins. Let him be well dried with a moderately
coarse towel, and then let his back be well rubbed, and his shoulders
be thrown back—exercising them, much in the same manner as in
skipping, for five or ten minutes at a time. Skipping, by-the-by, is of
great use in these cases, whether the child be either a boy or a girl—
using, of course, the rope backward, and not forward.
Let books be utterly discarded until his shoulders have become
strong, and thus no longer round, and his shoulder-blades have
become straight. It is a painful sight to see a child stoop like an old
man.
Let him have twice daily a teaspoonful or a dessertspoonful
(according to his age) of cod-liver oil.
When he is old enough, let the drill-sergeant give him regular
lessons, and let the dancing-master be put in requisition. Let him go
through regular gymnastic exercises, provided they are not of a
violent character.
 But, bear in mind, let there be in these cases no mechanical
restraints—no shoulder-straps, no abominable stays. Make him
straight by natural means—by making him strong. Mechanical
means would only, by weakening and wasting the muscles, increase
the mischief, and thus the deformity. In this world of ours there is
too much reliance placed on artificial, and too little on natural means
of cure.
259. What are the causes of Bow Legs in a child; and what is the
treatment?
Weakness of constitution, poor and insufficient nourishment, and
putting a child, more especially a fat and heavy one, on his legs too
early.
Treatment.—Nourishing food, such as an abundance of milk, and,
if he be old enough, of meat; iron medicines; cod-liver oil; thorough
ablution, every morning, of the whole body; an abundance of
exercise either on pony, or on donkey, or in carriage, but not, until
his legs be stronger, on foot. If they are much bowed, it will be
necessary to consult an experienced surgeon.
260. If a child, while asleep, “wet his bed,” is there any method of
preventing him from doing so?
Let him be held out just before he himself goes to bed, and again
when the family retires to rest. If, at the time, he be asleep, he will
become so accustomed to it that he will, without awaking, make
water. He ought to be made to lie on his side; for, if he be put on his
back, the urine will rest upon an irritable part of the bladder, and, if
he be inclined to wet his bed, he will not be able to avoid doing so. He
must not be allowed to drink much with his meals, especially with his
supper. Wetting the bed is an infirmity with some children—they
cannot help it. It is, therefore, cruel to scold and chastise them for it.
Occasionally, however, wetting the bed arises from idleness, in which
case, of course, a little wholesome correction might be necessary.
A waterproof cloth,[257] or bed-sheeting, as it is sometimes called—
one yard by three-quarters of a yard—will effectually preserve the
bed from being wetted, and ought always, on these occasions, to be
used.
A mother ought, every morning, to ascertain for herself whether
her child have wet his bed; if he have, and if unfortunately the
waterproof cloth have not been used, the mattress, sheets, and
blankets must be instantly taken to the kitchen fire and be properly
dried. Inattention to the above has frequently caused a child to
suffer, either from a cold, from a fever, or from an inflammation; not
only so, but if they be not dried, he is wallowing in filth and in an
offensive effluvium. If both mother and nurse were more attentive to
their duties—in frequently holding a child out, whether he asks or
not—a child wetting his bed would be the exception, and not, as it
frequently is, the rule. If a child be dirty, you may depend upon it the
right persons to blame are the mother and the nurse, and not the
child!
261. If a child should catch Small-pox, what are the best means to
prevent pitting?
He ought to be desired neither to pick nor to rub the pustules. If he
be too young to attend to these directions, his hands must be secured
in bags (just large enough to hold them), which bags should be
fastened round the wrists. The nails must be cut very close.
Cream smeared by means of a feather, frequently in the day, on the
pustules, affords great comfort and benefit. Tripe-liquor has, for the
same purpose, been strongly recommended. I, myself, in several
cases have tried it, and with the happiest results. It is most soothing,
comforting, and healing to the skin.
262. Can you tell me of any plan to prevent Chilblains, or, if a
child be suffering from them, to cure them?
First, then, the way to prevent them.—Let a child, who is subject
to them, wear, in the winter time, a square piece of wash-leather over
the toes, a pair of warm lamb’s-wool stockings, and good shoes; but,
above all, let him be encouraged to run about the house as much as
possible, especially before going to bed; and on no account allow him
either to warm his feet before the fire, or to bathe them in hot water.
If the feet be cold, and the child be too young to take exercise, then
let them be well rubbed with the warm hand. If adults suffer from
chilblains, I have found friction, night and morning, with horse-hair
flesh-gloves, the best means of preventing them.
Secondly, the way to cure them.—If they be unbroken, let them be
well rubbed, every night and morning, with spirits of turpentine and
camphorated oil,[258] first shaking the bottle, and then let them be
covered with a piece of lint, over which a piece of wash-leather
should be placed. “An excellent chilblain remedy is made by shaking
well together, in a bottle, spirits of turpentine, white vinegar, and the
contents of an egg, in equal proportion. With this the chilblains
should be rubbed gently whenever they are in a state of irritation,
and until the swelling and redness are dissipated.”[259]
If they be broken, let a piece of lint be spread with spermaceti
cerate, and be applied, every morning, to the part, and let a white-
bread poultice be used every night.
263. During the winter time my child’s hands, legs, etc. chap very
much: what ought I to do?
Let a teacupful of bran be tied up in a muslin bag, and be put, over
night, into either a large water-can or jug of rain water;[260] and let
this water from the can or jug be the water he is to be washed with on
the following morning, and every morning until the chaps be cured.
As often as water is withdrawn, either from the water-can or from
the jug, let fresh rain water take its place, in order that the bran may
be constantly soaking in it. The bran in the bag should be renewed
about twice a week.
Take particular care to dry the skin well every time he be washed;
then, after each ablution, as well as every night at bedtime, rub a
piece of deer’s suet over the parts affected: a few dressings will
perform a cure. The deer’s suet may be bought at any of the shops
where venison is sold. Another excellent remedy is glycerin,[261]
which should be smeared, by means of the finger or by a camel’s-hair
brush, on the parts affected, two or three times a day. If the child be
very young, it might be necessary to dilute the glycerin with
rosewater: fill a small bottle one-third with glycerin, and fill up the
remaining two-thirds of the bottle with rosewater—shaking the bottle
every time just before using it. The best soap to use for chapped
hands is the glycerin soap: no other being required.
264. What is the best remedy for Chapped Lips?
Cold-cream (which may be procured of any respectable chemist) is
an excellent application for chapped lips. It ought, by means of the
finger, to be frequently smeared on the parts affected.
265. Have the goodness to inform me of the different varieties of
Worms that infest a child’s bowels?
 Principally three—1, The tape-worm; 2, the long round-worm; and
3, the most frequent of all, the common thread or maw-worm. The
tape-worm infests the whole course of the bowels, both small and
large: the long round-worm, principally the small bowels,
occasionally the stomach; it sometimes crawls out of the child’s
mouth, causing alarm to the mother; there is, of course, no danger in
its doing so: the common thread-worm or maw-worm infests the
rectum or fundament.
266. What are the causes of Worms?
The causes of worms are—weak bowels; bad and improper food,
such as unripe, unsound, or uncooked fruit, and much green
vegetables; pork, especially underdone pork;[262] an abundance of
sweets; the neglecting of giving salt in the food.
267. What are the symptoms and the treatment of Worms?
The symptoms of worms are—emaciation; itching and picking of
the nose; a dark mark under the eyes; grating, during sleep, of the
teeth; starting in the sleep; foul breath; furred tongue; uncertain
appetite—sometimes voracious, at other times bad, the little patient
sitting down very hungry to his dinner, and before scarcely tasting a
mouthful, the appetite vanishing; large bowels; colicky pains of the
bowels; slimy motions; itching of the fundament. Tape-worm and
round-worm, more especially the former, are apt, in children, to
produce convulsions. Tape-worm is very weakening to the
constitution, and usually causes great emaciation and general ill
health; the sooner therefore it is expelled from the bowels the better
it will be for the patient.
Many of the obscure diseases of children arise from worms. In all
doubtful cases, therefore, this fact should be borne in mind, in order
that a thorough investigation may be instituted.
With regard to treatment, a medical man ought, of course, to be
consulted. He will soon use means both to dislodge them, and to
prevent a future recurrence of them.
Let me caution a mother never to give her child patent medicines
for the destruction of worms. There is one favorite quack powder,
which is composed principally of large doses of calomel, and which is
quite as likely to destroy the patient as the worms! No, if your child
have worms, put him under the care of a judicious medical man, who
will soon expel them, without, at the same time, injuring health and
constitution!
268. How may Worms be prevented from infesting a child’s
bowels?
Worms generally infest weak bowels; hence, the moment a child
becomes strong worms cease to exist. The reason why a child is so
subject to them is owing to the improper food which is usually given
to him. When he be stuffed with unsound and with unripe fruits,
with much sweets, with rich puddings, and with pastry, and when he
is oftentimes allowed to eat his meat without salt, and to bolt his
food without chewing it, is there any wonder that he should suffer
from worms? The way to prevent them is to avoid such things, and,
at the same time, to give him plenty of salt to his fresh and well-
cooked meat. Salt strengthens and assists digestion, and is absolutely
necessary to the human economy. Salt is emphatically a worm-
destroyer. The truth of this statement may be readily tested by
sprinkling a little salt on the common earthworm. “What a comfort
and real requisite to human life is salt! It enters into the constituents
of the human blood, and to do without it is wholly impossible.”[263]
To do without it is wholly impossible! These are true words. Look
well to it, therefore, ye mothers, and beware of the consequences of
neglecting such advice, and see for yourselves that your children
regularly eat salt with their food. If they neglect eating salt with their
food, they must, of necessity, have worms, and worms that will
eventually injure them and make them miserable.
269. You have a great objection to the frequent administration of
aperient medicines to a child: can you devise any method to prevent
their use?
Although we can scarcely call constipation a disease, yet it
sometimes leads to disease. The frequent giving of aperients only
adds to the stubbornness of the bowels.
I have generally found a draught, early every morning, of cold
pump-water, the eating either of loaf gingerbread or of oatmeal
gingerbread, a variety of animal and vegetable food, ripe sound fruit,
Muscatel raisins, a fig, or an orange after dinner, and, when he be old
enough, coffee and milk instead of tea and milk, to have the desired
effect, more especially if, for a time, aperients be studiously avoided.
 270. Have you any remarks to make on Rickets?
Rickets is owing to a want of a sufficient quantity of earthy matter
in the bones; hence the bones bend and twist, and lose their shape,
causing deformity. Rickets generally begins to show itself between
the first and second years of a child’s life. Such children are generally
late in cutting their teeth, and when the teeth do come, they are bad,
deficient of enamel, discolored, and readily decay. A rickety child is
generally stunted in stature; he has a large head, with overhanging
forehead, or what nurses call a watery-head-shaped forehead. The
fontanelles, or openings of the head as they are called, are a long
time in closing. A rickety child is usually talented; his brain seems to
thrive at the expense of his general health. His breast-bone projects
out, and the sides of his chest are flattened—hence he becomes what
is called chicken-breasted or pigeon-breasted; his spine is usually
twisted, so that he is quite awry, and, in a bad case, he is hump-
backed; the ribs, from the twisted spine, on one side bulge out; he is
round-shouldered; the long bones of his body, being soft, bend; he is
bow-legged, knock-kneed, and weak ankled.
Rickets are of various degrees of intensity, the hump-backed being
among the worst. There are many mild forms of rickets; weak ankles,
knocked-knees, bowed-legs, chicken-breasts, being among the latter
number. Many a child, who is not exactly hump-backed, is very
round-shouldered, which latter is also a mild species of rickets.
Show me a child that is rickety, and I can generally prove that it is
owing to poor living, more especially to poor milk. If milk were
always genuine, and if a child had an abundance of it, my belief is
that rickets would be a very rare disease. The importance of genuine
milk is of national importance. We cannot have a race of strong men
and women unless, as children, they have had a good and plentiful
supply of milk. It is utterly impossible. Milk might well be considered
one of the necessaries of a child’s existence.
Genuine fresh milk, then, is one of the grand preventives, as well
as one of the best remedies, for rickets. Many a child would not now
have to swallow quantities of cod-liver oil if previously he had
imbibed quantities of good genuine milk. An insufficient and a poor
supply of milk in childhood sows the seeds of many diseases, and
death often gathers the fruit. Can it be wondered at, when there is so