Dec 9, 2010

Child Abuse and Alcohol Abuse-a link

Child abuse is a significant public-health problem with 794,000 confirmed cases in the U.S. in 2007. The Centers For Disease Control's Adverse Childhood Experiences studies have documented this link quite clearly. It is a risk factor for a number of different problems including alcohol abuse, but less is known about this link in boys than in girls.

Researchers from the University of Southern California, Los Angeles studied 3,527 men aged between 17 and 56. Approximately 9% of the participants reported childhood maltreatment - defined as serious neglect or physical or sexual abuse occurring before the age of 15. Those who had been abused were 74% more likely to develop an alcohol problem.

Young-Wolff, K.C. ... [et al] - Accounting for the association between childhood maltreatment and alcohol-use disorders in males: a twin study Psychological Medicine (2011), 41, 59–70

For more information go to The Center For Family Development

Dec 6, 2010

Effects of Institution care on adoptees

What happens when children from severely-deprived institutional backgrounds are adopted into caring families?

Many children adopted internationally have spend months or years in institutional settings. Orphanage care can, at best, be described as neglectful. There is often multiple caregivers and little consistency in care. The opportunity for a caregiver to develop a sensitive, attuned, and responsive relationship with the infant/child is limited or non-existent.

We are finding some answers to these questions bit by bit, as the English and Romanian Adoptees (ERA) Study continues to follow a group of over 300 children adopted from Romanian orphanages in the early 1990s. The ERA researchers are in the process of comparing the Romanian adoptees to non-adopted children as well as to adopted children who never had institutional care. This work is enormously time-consuming and complex, and involves repeated measurements and interviews at different ages, plus delays associated with analyzing, writing, and publishing the results of each phase of the investigation.

A recent presentation of the children’s characteristics up to age fifteen has been published by Michael Rutter and co-authors as "Deprivation-specific psycholcogical patterns: Effects of institutional deprivation" (Monographs of the Society for Research in Child Development, Serial No. 295, Vol.75, No. 1, 2010). The 252 pages of this monograph are absolutely packed with information.

An aspect of the monograph that will be of interest to many is the question raised in the title: whether there are psychological patterns that follow severe social and other deprivation in early life. The ERA investigated a group of characteristics that seemed more likely to occur in post-institutional children than in other adoptees. The following items were included:

1. Quasi-autism: A behavior pattern not identical with autism, but including rocking, self-injurious behavior like hair-pulling, unusual and exaggerated sensory responses, and tantrums in response to changes in routine, as reported in parent interviews (Gindis, B. [2008]. Institutional autism in children adopted internationally: Myth or reality? International Journal of Special Education, 23, 118-123).

2. Disinhibited attachment, as shown in unusual friendliness toward strangers and failure to show strong preferences for familiar people in threatening circumstance. The monograph describes disinhibited attachment as including “inappropriate approach to unfamiliar adults, a failure to check back with a caregiver in unfamiliar settings, and willingness to accompany a stranger and wander away from a familiar caregiver. It is often associated with a lack of appropriate physical boundaries, so that children may interact with strangers intrusively and even seek out physical contact… there is sometimes inappropriate affectionate behavior with strangers and undue physical closeness” ( Monograph, p. 58) .

3. Cognitive impairment, including problems with “mentalization” or the ability to understand what other people might believe or feel about a situation.

4. Inattention and overactivity similar to attention-hyperactivity disorders.

While by no means all children who had come from institutions displayed these problems, even those who had spent more than 6 months in a Romanian orphanage, the ERA group reported that over 90% of those who still showed the behaviors at age 15 had spent more than 6 months in severe deprivation. Those who persisted to age 15 with these problems had often improved (for example, become more likely to be helpful or comforting to others), but odd behaviors still occurred. Some children “annoyed other people but did not know why, and difficulties making or keeping friends were common… In a few cases, … inappropriate remarks included excessively outspoken sexualized use of language” ( Monograph, p. 86). Some children were reported as fascinated with collections, including those of “useless rubbish” like chocolate wrappers.

Nov 27, 2010

Child Abuse and Drug Addiction: an important link

Child abuse is known to be a risk factor for a number of different mental-health problems and antisocial behaviour. For example, the Center's for Disease Control's famous Adverse Childhood Experiences research found a strong link between various adverse experiences in childhood and later physical, social, and mental health problems.

Researchers from the Albert Einstein College of Medicine in New York studied 143 people in an attempt to find out more about the link between child abuse and drug addiction. 48 of them were child molesters, 25 were recovering opiate addicts and the rest formed a healthy control group. The participants were asked whether they had suffered adult sexual advances while they were children or if they had had sexual intercourse with someone at least five years older before they were 13. The participants who were child molesters or recovering opium addicts had lost their virginity at a younger age than the healthy controls. However, while the child molesters were more likely to have been abused themselves the recovering addicts were no more likely to have suffered child abuse than the control group. But, this was a relatively small study and a number of other researchers have found a link between child abuse and drug addiction.

Cohen, Lisa J. ... [et al] - Comparison of Childhood Sexual Histories in Subjects with Pedophilia or Opiate Addiction and Healthy Controls: Is Childhood Sexual Abuse a Risk Factor for Addictions? Journal of Psychiatric Practice 16(6):394-404, November 2010

Center for Family Development

Nov 17, 2010

Childhood trauma memories: New Research

Psychologists have researched how people's memories of a traumatic event can effect how likely they are to develop post-traumatic stress disorder (PTSD) as a result of it. They've found that among adults with PTSD and acute stress disorder (ASD) trauma memories are fragmented and disorganised; are expressed more through the senses than words, and show increased emotional content. However, there has been much less research into how this process works in children. Researchers from the Institute of Psychiatry, King's College London studied 50 children being treated in hospital after an assault or a road-traffic accident. Some of the children developed ASD while others didn't and the children were asked to write the story (or narrative), both of the traumatic event itself and of another event which was unpleasant, but not traumatic. The children with ASD had significantly higher levels of disorganization in their trauma narrative compared to children without ASD and with their own non-trauma narrative. For all the children trauma narratives had significantly higher sensory content and lower positive emotion content than the comparison story. The severity of the children's ASD symptoms was significantly predicted by the level of disorganisation in the trauma narrative and the child's negative appraisals (e.g. 'this event has ruined my life,' 'I'm going mad to feel like this.') of the event.

Salmond, C. H. ... [et al] - The nature of trauma memories in acute stress disorder in children and adolescents Journal of Child Psychology and Psychiatry doi: 10.1111/j.1469-7610.2010.02340.x

Nov 12, 2010

Instutional life has negative effects on Executive Function

Previous research has shown that children who have spent at least some part of their life in an institution tend to have problems with executive functions. Executive functions are higher brain functions such as working memory, the ability to inhibit one's behavior, forward planning, the ability to move from one task to another, impulse control, the ability to start or initiate, and attention. Instruments such a the Behavior Rating Inventory of Executive Function can be used to measure executive functions.

Past research has concentrated on children aged between six and eleven so researchers at the University of Pittsburgh studied 418 children who had been adopted from institutions in Russia where they had been psychologically, but not physically, deprived. 130 of the children were pre-school age while the rest were older. The study found that the older the age the children had been adopted at the worse their executive function was and that those who were adopted after they were 18 months old had worse executive function than those who had been adopted when they were younger. The onset of adolescence was associated with a greater increase in executive function deficits for children adopted after 18 months than for those adopted when they were younger.

Merz, E. C. and McCall, R. B. Parent ratings of executive functioning in children adopted from psychosocially depriving institutions Journal of Child Psychology and Psychiatry doi: 10.1111/j.1469-7610.2010.02335.x

A study using the Vineland Adaptive Behavior Scales found similar delays, lags, and problems among a group of adopted children.
Becker-Weidman, A., (2009) “Effects of Early Maltreatment on Development: A Descriptive study using the Vineland,” Child Welfare, 88 (2)137-161.
Also see The Center For Family Development for very useful information.

Nov 10, 2010

Child Abuse & Psychosis: a link?

There is a growing recognition that having a difficult or traumatic childhood can increase the likelihood of people developing psychosis later in life but it is difficult to untangle what types of trauma or abuse are linked to an increased risk. A team of researchers from the Institute of Psychiatry, King's College London, UK, looked into this in a study of 428 people, 182 of whom had psychosis. The researchers asked people about difficulties and problems in their childhood and found that people with psychosis were three times more likely to report severe physical abuse by their mother before they were 12. There was also some - although not statistically significant - evidence that 'severe maternal antipathy' was linked to an increased risk of psychosis. However, paternal maltreatment and other forms of adversity were not linked to an increased risk of psychosis.

This is another important study the implications of which are that child abuse is a major public health issue with significant implications for later functioning. The Adverse Child Experiences research by the US Centers for Disease Control also point in the same direction. The ACE's studies clearly demonstrate that adverse childhood experiences result in later significant health difficulties, among other problems.

Fisher, H.L. ... [et al] - The varying impact of type, timing and frequency of exposure to childhood adversity on its association with adult psychotic disorder Psychological Medicine (2010), 40, 1967–1978

Oct 16, 2010

Cognitive Processing

Many children with histories of chronic early maltreatment within a care-giving relationship have been prenatally exposed to alcohol and/or drugs. The timing of the exposure and the intensity of prenatal exposure can have differing effects on the developing fetus, psychological functioning, and cognitive functions. These effects can sometimes be very subtle and not noticed or misinterpreted.

For example, some children are described as oppositional and defiant when what we may be observing is a cognitive processing and developmental deficit. As an example of this, the child may be perfectly capable of making a peanut butter and jelly sandwich. However, if you put a jar of peanut butter, a jar of jelly, a plate, knife, and bag of bread on the table and ask the child to tell you how to do this, you may find that the child had great difficulty doing so. This is a not uncommon experience with children prenatally exposed to chemicals. Understanding this cognitive processing deficit can be helpful for teachers and parents and ensure that the child's behavior is not misinterpreted.

Becker-Weidman, A., & Shell, D., (Eds), Attachment Parenting, Jason Aronson, Lanham, MD, 2010.

Sep 18, 2010


I have written a new book,
Dyadic Developmental Psychotherapy: Essential Practices & Methods
which is due out later this year. It is as close to a treatment manual as one can get with an experimentally based approach for this evidence-based, effective, and empirically validated treatment.

The book describes the theory base of Dyadic Developmental Psychotherapy and the evidence base of the approach. Another chapter describes fourteen components of Dyadic Developmental Psychotherapy. A major chapter in the book describes the phases of treatment:
Developing the Alliance
Maintaining the Alliance
and the differential uses of the components of Dyadic Developmental Psychotherapy in these phases.
There are chapters about working with care-givers and the importance of caregivers as the key-stone for successful treatment

The book has extensive transcripts and excerpts from actual treatment sessions to illustrate the components and phases and principles being described.

Therapists, parents, psychologists, researchers, professors, social workers, residential treatment staff, and child welfare staff will all find this book a valuable resource.

Sep 4, 2010

Dyadic Developmental Psychotherapy WIKI

There is a new Wiki devoted to Dyadic Developmental Psychotherapy that readers may want to view.
Click on this link to get there.

The url is:

The Wiki has just started, but already has many articles about Dyadic Developmental Psychotherapy and related topics that readers will find quite useful and interesting.

Aug 15, 2010

Fathers matter!

Most psychological research into parenting concentrates on the role of mothers but having a good relationship with one's father can also help people to cope better in later life. Researchers from California State University, Fullerton studied 912 people between the ages of 25 and 74. Over eight days they interviewed the participants about that day's experiences asking them about their mental state and any stressful events. The participants were also asked about the quality of their childhood relationships with their parents. The study found that more people were likely to say their childhood relationship was better with their mother than with their father; a difference that was more pronounced among men. People who had had a good relationship with their mother reported 3% less psychological distress compared to those who reported a poor relationship. Men who had had a good relationship with their father also reported less psychological distress but this effect was not as strong among women.

Researchers spoke to more than 900 men and women aged from 25 to 74 before reaching their conclusion.

Psychology Professor Melanie Mallers, of California State University-Fullerton, who led the research team, said: "Most studies on parenting focus on the relationship with the mother.
"But, as our study shows, fathers do play a unique and important role in the mental health of their children much later in life."

As part of the study, 912 adult men and women completed short daily telephone interviews about that day's experiences over an eight-day period.

The interviews focused on the participants' psychological and emotional distress - such as whether they were depressed, nervous, or sad - and if they had experienced any stressful events that day. These events were described as arguments, disagreements, work-related and family-related tensions and discrimination.

The participants also reported on the quality of their childhood relationships with their mother and father. For example, they answered questions such as: "How would you rate your relationship with your mother during the years when you were growing up?" and "How much time and attention did your mother give you when you needed it?"

The same questions were asked about fathers. The research took into account age, childhood and current family income, neuroticism and whether or not their parents were still alive.

Prof Mallers and her team found participants were more likely to say their childhood relationship with their mother was better than with their father, with more men reporting a better mother-child relationship than women.

People who reported they had a good mother-child relationship reported three per cent less psychological distress compared to those who reported a poor relationship.

Prof Mallers said: "I don't think these results are surprising, given that past research has shown mothers are often the primary care-giver and often the primary source of comfort.

"It got interesting when we examined the participants' relationship with their fathers and their daily emotional reaction to stress."

They also found that men who reported having a good relationship with their father during childhood were more likely to be less emotional when reacting to stressful events in their current daily lives than those who had a poor relationship. This was not found to be as common for the women in the study.

And Prof Mallers said the quality of mother and father relationships was significantly associated with how many stressful events the participants confronted on a daily basis. In other words, if they had a poor childhood relationship with both parents, they reported more stressful incidents over the eight-day study when compared to those who had a good relationship with their parents.

Prof Mallers said: "Perhaps having attentive and caring parents equips children with the experiences and skills necessary to more successfully navigate their relationships with other people throughout childhood and into adulthood."

She said it was difficult to come up with a concrete theory as to why men's relationship with their father had such an influence on their emotional reaction to stress, especially since this study included adults of all ages who were raised during very different eras in the United States.

Prof Mallers added: "The role of fathers has changed dramatically from the time the oldest participants were children.

"We do know that fathers have a unique style of interacting with their children, especially their sons.

"We need more research to help us uncover further influences of both mothers and fathers on the enduring emotional experiences of their children."

Prof Mallers presented the findings at the 118th Annual Convention of the American Psychological Association in San Diego.

Jul 5, 2010

Update on Artym

(July 2) -- Torry-Ann Hansen, the Tennessee nurse who adopted 7-year-old Artyom Savelyev and then returned him because she said he wanted to kill her, apparently never bonded with the Russian boy. But she did give him a new name (Justin), a new language (English) and comfort food (burgers and fries, with ketchup).

For now, Artyom, once again under the care of the Russian state, is not being fed hamburgers, said Pavel Astakhov, the point man on all things Artyom -- though there is talk of ordering out for the boy's second-favorite dish, pizza. The Russians have also junked the American name ("He's Artyom in Russian Federation," one official said), but they're making sure he doesn't lose his English. "It's very important for his future," Astakhov explained.
In an image taken from Rossia 1 television channel, 7-year-old adopted Russian boy Artyom Savelyev gets into a minivan outside a police department office in Moscow, April 8.
Rossia 1 Television Channel / AP
In an image taken from Russian television, 7-year-old Artyom Savelyev gets into a minivan outside a police department in Moscow on April 8. Torry-Ann Hansen, the Tennessee woman who adopted Artyom, created a firestorm when she sent him back to his home country of Russia.

It is not exactly true that Artyom Savelyev has been transformed into the Russian Elian Gonzalez. While many Russians pity Artyom, no one is throwing any parades for him. Still, the analogy is not totally off base.

Less than a year ago, Artyom was living in an orphanage in the town of Partizansk, nine time zones east of Moscow and a few stops from the end of the Trans-Siberian Railway. He had been consigned to a remote corner of a vast country that doesn't think much of orphans -- had he never left the Russian Far East, odds are that Artyom would have faced prison, homelessness, venereal disease and/or premature death. And then, he was magically airlifted to America.

But for Hansen, it turned out that parenting a boy who may have been a victim of fetal alcohol syndrome and definitely had been subjected to violence and hunger was, well, trying. So on April 7, seven months after he arrived in his new hometown of Shelbyville, Tenn., Artyom's new grandmother took him to Dulles International Airport outside Washington. There, Nancy Hansen turned him over to the custody of United Airlines, and he was put on Flight 964 to Moscow's Domodedovo Airport. The flight would be just shy of 10 hours.

Landing in Moscow, he was met by Artur Lukyanov, who had been paid $200 by Nancy Hansen to take him to the Ministry of Education and Science, which has jurisdiction over adoptions. At the ministry, in Moscow's center, Lukyanov gave officials a letter from Torry-Ann Hansen claiming that Artyom had "severe psychopathic issues" and wanted to burn her house down.

Artyom's story soon became a Russian story -- about suffering, fortitude and a child's innocence. Because Artyom was no longer just Artyom but a metaphor for something much bigger, his story had to end triumphantly. America, in the guise of Torry-Ann Hansen, had rejected Russia, and then Russia, in the guise of Artyom, was saved by the Russian state.

And so it was that on April 8, when the twice-abandoned Elian Gonzalez of Siberia -- having zigzagged from post-Soviet backwater to Dixieland nightmare to the loving embrace of the Kremlin -- stepped off an airplane outside Moscow, his journey, Russia's journey, finally began to look up. That was the day everything turned around.

Into the Arms of the State

Artyom's story, naturally, requires an expert storyteller. That Pavel Astakhov has been assigned to that role suggests the Kremlin knows as much.

Astakhov, the 43-year-old, permanently tanned, coiffed and manicured superlawyer whom President Dmitry Medvedev late last year named children's rights commissioner, is the Judge Judy of Russia. Besides running a bustling practice -- according to his website, former clients include Moscow Mayor Yury Luzhkov and accused American spy Edmond Pope -- Astakhov hosts the television program "Chas Suda," or "Hour of the Court."
Russian Presidential Commissioner for Children's Rights, Pavel Astakhov, shows a copy of Artyom Savelyev's US passport to journalists near a children's hospital in Moscow on April 16.
EPA / ZUMA Press
Pavel Astakhov, the Russian presidential commissioner for children's rights, shows a copy of Artyom Savelyev's U.S. passport to journalists near a children's hospital in Moscow on April 16.

The program, which airs daily on state-run Ren TV, amounts to a propaganda organ meant to convince Russians that the Russian Federation is ruled by laws, not men (which is not true). In Judge Astakhov's courtroom, justice is all that counts, not bribes or boyars or even Vladimir Putin. As Astakhov's site notes, "Chas Suda" "creates respect for the law" and "contributes to a positive image of the court in the minds of the people."

Like celebrities everywhere, but especially in Russia, it is important to Astakhov that other people know he is always busy. The first time I called him, on his cell, he didn't answer; nor did he pick up the second, third or fourth time. Eventually, I sent him a text message, and a minute later Astakhov wrote back, saying I should call his assistant. After several scheduled phone interviews that never materialized, I caught the judge in his car going somewhere that, he said, was very important.

On the phone, he was guarded -- not the way lawyers can be guarded, choosing their words carefully to avoid being accused of something they didn't mean; rather, the way celebrities are guarded, shielding from public view the gilded utopia they inhabit.

Artyom, Astakhov said, had been removed to an "undisclosed location" -- an orphanage -- in central Moscow. "It's a special house for orphans," he said. "There are many specialists around him -- pedagogues, psychologists, teachers -- and only five children in this house right now. He is living in one room with a boy of his age." He said Artyom had been put on a special diet for children in his age group (he wouldn't specify what this consisted of) and that doctors had run a battery of tests on him.

Implying not so subtly that Torry-Ann Hansen must be crazy or blind, he added, "He is absolutely normal. I spoke with Artyom many, many times. I saw all the medical exams about his conditions, I mean, mentally and physically, and Artyom is very well."

Lukyanov, the driver, agreed with Astakhov. He said Artyom seemed like a regular little boy when he stepped off the plane. He was wearing a yellow jacket and had a Spider-Man backpack with a Spider-Man doll, a miniature car and pencils inside. But he was confused about where -- and who -- he was. While they were in Lukyanov's Ford heading into Moscow, Artyom began to cry and ask for his "Grandma Nancy." "The boy could not calm down for a few minutes," Lukyanov wrote on his website.

(Lukyanov posted a lengthy dispatch on the site after being accused, in Russia, of abandoning Artyom at the ministry. He insists he stayed with Artyom all day, until he deposited him at Hospital 21, a state children's hospital on the northeastern fringe of the city.)

"When I met him, I didn't know that he is Russian," Lukyanov told me. "After, in the office of the ministry, we recognized that within six months [in the United States] he had forgot his native language ... or pretended that he forgot. At the end of the day, he remembered Russian words and began to understand us better and better."

Astakhov said Artyom was not ready to meet journalists. Nor would he reveal any details about the orphanage where he's staying except to say it has had remarkable success placing orphans with foster and adoptive families. (In the past year, Astakhov said, the orphanage has placed 150 children. He did not say if these children had been placed with foreigners or Russians, who are generally resistant to taking in parentless children.)

That said, photographs of a smiling Artyom at the orphanage have popped up on the website of the state news agency RIA Novosti. In one picture, Artyom, in a short-sleeve, blue-and-white striped shirt, plays with the iconic wooden toy known as a matryoshka doll. Behind the little boy, with his tousled blond hair and toothy grin, is a bright orange stuffed bear and a freshly made twin-sized bed.

"The most traumatic months were in Torry's family, when she pulled his hair and she punished him for everything," Astakhov said. " 'Don't cry, don't yell, don't play, don't go out from this house.' Everything was prohibited for Artyom. I think it's over, and now we are doing all the best for Artyom's future, for Artyom's present."

America and the Scandale d'Artyom

One reason English could be important for Artyom's future is that he may opt to go back to America. That would be easy enough since he is now a dual citizen of Russia and the United States, which granted him citizenship when Hansen adopted him. As one former diplomat put it, "Your mother may give you back, but your motherland never will."

Astakhov said Julie Stufft, a U.S. Embassy official, had visited with Artyom at the orphanage. Stufft referred questions about the boy to embassy spokesman Kevin Kabumoto, who refused to discuss the case, citing the Privacy Act. Tom Armbruster, the U.S. consul general in Vladivostok, cited a May 13 statement issued by the State Department on U.S.-Russian talks on adoption and, presumably, how to make sure that people like Torry-Ann Hansen (or, worse yet, Peggy Sue Hilt, who in 2006 pleaded guilty to killing the Russian girl she'd adopted) don't wind up with future Artyoms.
Artyom Savelyev plays in a children's hospital in Moscow, Russia on April 9.
EPA / ZUMA Press
Artyom Savelyev is all smiles as he plays in a children's hospital in Moscow on April 9.

"Both teams are committed to reach an agreement to increase safeguards for intercountry adoption," Mary Ellen Hickey, head of the U.S. delegation, said in the statement. Furthermore, whatever agreements are hammered out will be "legally binding" and "each country will define its competent bodies responsible for coordinating bilateral cooperation in adoption."

That is exactly what the United States has resisted and Russia has sought for years. What brought an end to the impasse was the scandale d'Artyom. The Americans were embarrassed. The Russians were livid. Finally, the political alignment had shifted, and the Americans -- who have sought to make nice with the Russians ever since Barack Obama reset relations with the Kremlin -- signed off on a slew of new regulations and identity checks.

The final agreement, details of which have yet to be made public, is expected to be signed in a few months. This makes Russia happy (victory over America!) and comes at a low cost to the Obama administration: Many, if not most, of the people who adopt Russian children are churchgoing -- many got the idea to adopt a Russian child while doing missionary work in the former Soviet Union -- and white. (Adoption officials say Russia is a popular destination for adoptive U.S. parents because it has a huge cache of parentless kids with the "correct" skin color, unlike, say, China.) This is a constituency that did not vote for Obama in 2008 and is unlikely to do so in 2012.

Too Many Children, Not Enough Homes

Since the 1991 Soviet collapse, American families have adopted more than 50,000 Russian children. The pace of adoptions held steady in the 1990s but began to drop in 2003. Although no one at the Kremlin ever articulated a change in policy -- the Kremlin rarely, if ever, articulates changes in policy -- that decline parallels a shift in attitudes at the very top toward foreigners and especially Americans.

Now, a mere 1,700 to 1,800 Russian children are adopted by Americans yearly, despite ongoing demand. "It's all about saving the children," said Michelle Helton Jayroe, who traveled in December 2008 from her Alabama home to Samara, about 550 miles southeast of Moscow, with a friend who was adopting a little boy. "She would adopt 25 if her husband would allow. ... She's hoping for two more, at least."

That is likely to get tougher. Russia has permitted foreigners to adopt its children because there are not enough Russians to take them in. That's because most Russians are poor: In 2008, Russia ranked No. 75 in per capita income, with the average Russian grossing the equivalent of $9,660, between No. 74 Mexico and No. 76 Chile, according to a World Bank report this year.

And it's because, since Soviet times, there has been a stigma attached to orphans. "For many years, if a Russian family decided to adopt a child, they would fake a pregnancy," said Ekaterina Bridge, head of the Russian branch of the World Association for Children and Parents, the Renton, Wash., agency that facilitated Artyom's adoption. "They didn't want that someone would later tell their child. They'd prefer not to tell the child that he had been adopted."

Moscow has never been happy about the need for foreigners to pick up the slack. Like capitalism and world peace, the Russian leadership tends to view adoption as an instrument that may or may not serve its interests; the fact that these interests often diverge from those of Russia's roughly 700,000 orphans, most of whom remain in orphanages, is irrelevant.

This is especially troubling to parentless teenagers on the verge of "graduation." Every year about 20,000 kids, having recently turned 17, leave Russian orphanages, according to Anna Sergeeva, director of the New York office of the Russian Children's Welfare Society. "A majority of them fall into a high-risk category (crime, homelessness, prostitution)," she wrote in an e-mail. "Ten percent commit suicide, and only 4 percent are admitted to colleges or universities."

These figures would seem to suggest that Russia should push for more, not fewer, adoptions. Not so: Sergeeva predicted the number of adoptions would drop again this year.

A Country's Outrage -- and Ambivalence

Artyom's story, like that of the Iraq War and the Bush administration's handling of Hurricane Katrina, has provided the Russian state with a prophylactic that safeguards it against external criticism -- We're all rotten, aren't we? But more important, it reaffirms Russia's idea of Russia, that of a battered and impoverished people that fights and perseveres and defies the many forces arrayed against it: fascists, imperialists, CIA agents and, of course, soulless would-be mothers from Tennessee.

Alexandra Ochirova, an adoption specialist who sits on the 126-member Public Chamber, a government panel that is meant to serve as the nation's public conscience, was reflecting on the nature of motherhood. We were at the Winter Garden Cafe, at the National Hotel, across the street from Red Square, and Ochirova was sipping an espresso. She said she was deeply troubled -- pained -- by the case of Artyom Savelyev. "The only motivation to adopt a child is love," Ochirova declared. "This is all that must be there."

(Pavel Astakhov agreed when we spoke. "You really need only love and attention and, of course, patience. For example, Torry Hansen didn't have patience, love or attention.")

What about medical records? I asked Ochirova. Hansen had claimed that orphanage officials in Partizansk withheld information about Artyom that would have alerted her to his behavioral problems. "What information?" Ochirova said. "Was he a terrorist? A killer? Perhaps she was unaware that he didn't enjoy a king's upbringing."

When she was at Moscow State University, Ochirova studied philosophy (Immanuel Kant, Georg Hegel and, of course, Karl Marx) and the greatest of all Russian prophets, Fyodor Dostoevsky. The world would be a better place, she said, if its leaders, beginning with Barack Obama, read more Russian literature and especially more Dostoevsky, whose most famous novel, "The Brothers Karamazov," ends with a little boy's funeral.

She asked if Obama had been following the story of Artyom. I said that I had no idea but that he probably had other things to worry about: the oil spill, the economy, the war in Afghanistan. Ochirova became livid. "What can possibly be more serious than this problem? This is the first problem. What we really need is a new moral order."

No doubt. There's something strange about a country that is teeming with unwanted children and has no one to take them in and can't decide if it should let other people, in other countries, fill that niche. That ambivalence inhibits action, which spawns backlog and, ultimately, a permanent subset of parentless children.

Exhibit A: Artyom Savelyev, Russia's most famous parentless child. Adoption officials, Astakhov said, are reviewing the applications of three families hoping to adopt Artyom. Astakhov stressed that all of the families are Russian, but then he said that that is not important. "A little boy, a little girl, are very flexible. It does not matter to them."

In two to three months, Artyom will be placed in a new home, and then his life will begin. Astakhov wouldn't say much about the candidate families -- for instance, where they were before Torry-Ann Hansen showed up -- except that they live in Moscow and that they are all "promising."

"One of these families," Astakhov said, "is the family of former diplomats who have good experience with adopted children because they raised a boy who was adopted many years before. This family will be the best family for Artyom. Both mother and father speak English very well."

Peter Savodnik is a writer based in New York. His book about Lee Harvey Oswald's time in the Soviet Union, provisionally titled "The Interloper," will be published by Basic Books next year.

Suicide and Child Abuse: a link

Suicide is one of the leading causes of death worldwide but what causes it is still not well understood. Mental-health problems are an important risk factor but most people with a mental-health problem do not think about killing themselves. There is strong evidence that people's experiences contribute more towards their mental-health problems than their genes and that bad experiences in people's childhood are linked to more thoughts about, or attempts at, killing oneself in later life. However, there has been less research into this than into genetic factors or mental-health problems. A team of researchers led by Ronny Bruffaerts from Gasthuisberg University Hospital in Belgium studied an international sample of 55,299 people asking them about their experiences in childhood and whether they had thought about, or tried to kill themselves. They found that bad experiences in childhood were associated with an increased risk of suicide attempts and thoughts of suicide. Sexual and physical abuse, especially during adolescence, were consistently the strongest risk factors.

Bruffaerts, Ronny ... [et al] - Childhood adversities as risk factors for onset and persistence of suicidal behaviour. British Journal of Psychiatry, July 2010, 197(1), 20-27


May 2, 2010

Adoption: What disclosures are requuired?

The lawsuit described in a recent New York Times article by Pam Belluck raised important questions regarding the disclosures that should be made by adoption agencies to their adoptive families.

At the Center for Family Development we frequently find that families have not been fully or adequately informed regarding the mental health, health, and psychological status of the child they are wanting to adopt. In many instances the agency has not informed the family of the potential risks and issues that may be presented. We find that this lack is more common in international adoptions, and particularly in those programs that bring a child to the US for a few weeks for "camp," with a family, and more often with adoptions from Russian and Eastern Europe. We do find that agencies doing domestic adoptions of children in the child welfare system seem to do a more comprehensive job of fully informing parents of actual and potential issues.

By Pam Belluck
New York Times
Apr 28, 2010

Scores of complaints have been made in recent years against adoption agencies by people claiming they were inadequately informed or ill-prepared for problems their children turned out to have.

Many state laws and the Hague Convention now require agencies to disclose “reasonably available” records. But it can be unclear, especially in international cases, how assertive they are expected to be in getting such information.

The case of Chip and Julie Harshaw of Virginia Beach is, in some ways, the reverse of the now-familiar story of a Tennessee mother who put her Russian-born child on a plane home: The Harshaws are committed to raising their Russian son, even though they say they would not have adopted him had they known how severely impaired he was. But when they decided to adopt, the Harshaws told their agency they could care only for a child with minimal health problems and “a good prognosis for normal development,” according to notes in the adoption agency’s paperwork.

They rejected one child because he had abuse-inflicted burns. But when a toddler in a Siberian orphanage appeared to fit their criteria, they brought the boy, Roman, home. ” ‘A beautiful, healthy, on-target, blond-haired boy’ was what they had quoted to us,” Julie Harshaw said.

After the adoption in 2004, Roman began showing “uncontrollable hyperactivity” and aggression, Julie Harshaw said. He has threatened their 5-year-old biological daughter with a steak knife and a two-by-four, and held her underwater in a pool. Their 13-year-old biological son has felt so much stress that he has required therapy.

Therapeutic programs have ejected Roman for kicking, biting, hitting and, most recently, on his 8th birthday, pulling out three of his teeth using a pen cap, fork or spoon.

Doctors finally diagnosed fetal alcohol spectrum disorder, brain damage and neuropsychiatric problems in Roman, whose IQ is 53. He was recently placed in an institution and is not expected to ever live independently, one of his doctors said.

The Harshaws are suing the agency, Bethany Christian Services, seeking compensation for the care Roman will need.

After Roman’s problems were diagnosed, the agency offered to end the adoption, to try placing Roman with another family. The Harshaws refused. “He’s not a dog; you don’t take him to a pound,” Julie Harshaw said.

The family claims that Bethany indicated, inaccurately, that a Russian doctor working for the agency had examined Roman, and that Bethany gave them incomplete medical information when more detailed records were available. (Such records were produced by Bethany more than two years later.)

Bethany, which calls itself “the nation’s largest adoption agency,” disputes most of the claims.

“Bethany is a highly respected adoption agency that provided all the appropriate information for consideration by the Harshaws,” said Mark Zausmer, a lawyer for Bethany, based in Michigan. “Bethany provided this family counseling, extensive documentation, opportunities to consult with physicians, medical records and other materials from which they could fully evaluate how to proceed.”

No organization tracks the number of cases against adoption agencies, and academics and industry officials say many are settled out of court and sealed, so the outcomes are unknown.

But these days, “a far greater percentage of these wrongful adoption suits relate to international adoptions,” said Marianne Blair, a University of Tulsa law professor.

Chuck Johnson, acting chief executive of the National Council for Adoption, an advocacy group, said, “There have been a growing number of families that have sued when they adopted a child from another country.”

Some lawsuits, Johnson said, come from families “expecting you to do the impossible when you did all you could,” but he said there had also been “agencies that have purposely concealed information.”

Issues of disclosure have drawn increasing attention in recent years. Lawsuits erupted in the 1980s over domestic adoptions in which histories of abuse and other problems were kept from adoptive parents.

“The philosophy was the blank slate, that adoption is a new start,” Blair said. Now, she said, experts believe that “disclosure of health information is vital.”

As a result, many states enacted disclosure laws, followed by similar requirements in the Hague Convention, which apply to countries that ratify the treaty, as the United States did in 2008. Russia has signed the agreement but has not yet ratified it.

Those regulations were developing as the Harshaws’ adoption was proceeding, and at most agencies, “the atmosphere was definitely an emphasis in getting what could be obtained and making sure that they disclose that,” said Joan H. Hollinger, a law professor at the University of California, Berkeley, who is serving as an expert witness for the Harshaws. Agencies were also focused on “preparation of adoptive families for what they might encounter,” Hollinger said.

Bethany says it clearly advised the family that children from Russia could have problems, including serious ones, and that records might be inaccurate.

While the Harshaws’ pediatrician raised overall risks after reviewing a video of Roman and a two-page medical summary, observing that some of the notations could indicate learning disabilities, she saw no specific indications of severe problems on the pre-adoption records provided. She noted a lack of detailed, up-to-date information and said she could not see Roman’s face clearly. (Facial characteristics may provide clues to health deficiencies.)

“They were warned about generalities,” said their lawyer, Samuel C. Totaro Jr., but the agency caseworker told them a Russian-trained doctor based in New York had “gone over there and seen him, and you have a healthy, on-target child, and the family took great reassurance from that.”

In a deposition, the caseworker acknowledged she had said that the doctor, Michael Dubrovsky, visited the orphanages to “see the children” and review pictures, videos and medical information. The agency says the Harshaws misinterpreted that to mean Dubrovsky had examined Roman.

In a deposition, Dubrovsky said he had never seen Roman, had not practiced medicine for years and was a facilitator for Bethany, not a medical screener.

The agency also suggests that the fetal alcohol syndrome was unlikely to have been detected before the adoption, noting that the Harshaws did not receive that diagnosis until two years later.

Zausmer said the agency did not conceal information and provided a translated synopsis of the Russian medical records that was standard at the time.

“We don’t believe that there was anything in the Russian records that would have materially affected any adoption decision,” Zausmer said.

But Dr. Ronald S. Federici, a neuropsychologist who diagnosed Roman’s illness, said the full 10-page medical record the agency produced after the adoption, at the parents’ urging, would have shown that “the boy had fetal alcohol syndrome.”

The Harshaws hope the institution can stabilize Roman enough to send him home; either way, he will need extensive lifetime care.

“What we’ve been through and what we’ve lost,” Chip Harshaw said. “Every day is ‘Groundhog Day,’ a repeat of the stress and anger and frustration.”

Apr 28, 2010

Bipolar Disorder in Children: Is it being Over-diagnosed?

Is Bipolar Disorder being over-diagnosed in children?

Many people erroneously argue that it is, so let's take a look at the evidence. First, I am talking about children aged five years into adolescence who actually meet the full DSM-IV criteria for Bipolar Disorder. I am not discussing children who only have irritability or aggression without any other manic criteria.

In 1994/1995 the frequency of the Bipolar Diagnosis was 25 cases per 100,000. In 2002/03 the frequecny increaed over forty-fold to 1003 cases per 100,000. (See: National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth, Carmen Moreno, MD; Gonzalo Laje, MD; Carlos Blanco, MD, PhD; Huiping Jiang, PhD; Andrew B. Schmidt, CSW; Mark Olfson, MD, MPH, Arch Gen Psychiatry. 2007;64(9):1032-1039.)

Put another way, the diagnosis of Bipolar Disorder rose from 0.01% in 1994 to 0.44% in 2002. That is certainly a 40X increase, but is it really over-diagnosis?

The standard method to estimate the actual prevalence of psychiatric conditions is to conduct an epidemiological study, where trained researchers study large representative samples of the general population (not preselected clinical samples) with standardized, validated instruments (like the SCID or MINI or CIDI) to assess and diagnose the general population using DSM-IV criteria (not just irritability or aggression in children as bipolar disorder, for instance). Using those methods in over 5000 persons, the most recent analysis (see: Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication
Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS, Arch Gen Psychiatry. 2005;62:593-602.) reports a one year adult prevalence of bipolar disorder (types I and II) of 3.9%. In an analysis of age of onset in the same citation above, the study found that bipolar disorder began before adulthood in a substantial minority of persons: in 25% of persons, it began by age 17, in 10% it began by age 13.

Let's do the math now and see what results. Excluding the adolescents up to age 17, and using the lower range of the NCS data:
If 10% of bipolar disorder begins by age 13, and 3.9% of the total population is diagnosable with the condition using DSM-IV criteria in a community-based epidemiological study of actual prevalence, then how many children should that clinical study have diagnosed with bipolar disorder? 0.10 multiplied by 0.39 is 0.039, or 0.39%. If we round to 0.4%, then we have the actual prevalence of bipolar disorder in children. The vaunted 40-fold increase from near zero led to the diagnosis being made in 0.4% of children based on percentage of office visits.

0.39% is about the same as 0.44%, so the purported evidence for over-diagnosis seems underwhelming, to say the least.

Apr 27, 2010

Notes from ATTACh

The Association for the Treatment and Training in the Attachment of Children has achieved a number of major accomplishments recently. In addition to preparing and publishing a Therapeutic Parenting Manual, A Clinical Practice Manual, and a wonderful DVD, it wrote an influential letter to the DSM V committee advocating for the inclusion of a diagnosis of Developmental Trauma Disorder. This is exciting work. This international association, with members from across the US, Canada, Europe and Asia is quite influential. Parents and professionals should visit the website of Association for the Treatment and Training in the Attachment of Children.

The organization is now working on a number of projects that will benefit therapists and parents.

Apr 23, 2010

Anticonvulsant medications and potential risks

Certain anticonvulsant drugs could be associated with an increased risk of suicide, attempted suicide or violent death. Anticonvulsants are used to help people with epilepsy but can also be prescribed for bipolar disorder, mania, neuralgia, migraine and neuropathic pain. Researchers from Harvard Medical School analyzed data from 14 states about patients fifteen-years old and over who started taking anticonvulsants between July 2001 and December 2006. They found that the risk of suicidal acts was increased for gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazapine (Trileptal), tiagabine (Gabitril) and valproate (Depakote).

You can find out more about this research at

Apr 18, 2010

Artyom Savelyev

In today's New York Times there is an excellent editorial about the story of Artyom Savelyev (Sunday April 18, 2010, pg9) titled "A Safe, Loving Home."

As the editorial states, while we don't know all the facts and details, returning a child is "profoundly wrong." The response of the Russian Foreign Ministry, while understandable, is, in my opinion, also wrong. Since 1991 over 50,000 Russian children have been adopted by US families. Currently there are 250 adoptions nearly completed and 3,500 pending. Children do better in families than in orphanages. That being said, many children who come from orphanages, which are frequently over-crowded and understaffed, have a variety of difficulties that sometimes require very specialized care, such as Alcohol Related Neurological Dysfunction, Sensory-Integration Dysfunction, and various psychological and emotional problems caused by chronic early maltreatment.

The inadequacy of post-placement services for families is a problem that we can fix by requiring agencies to provide those services. The problem of inadequate information from the orphanages, under staffing, and over crowding is something the other government can and must fix.

Apr 11, 2010

Artyom Savelyev & Torry Hansen’s Case

This is a very sad case for the child, first and foremost, for the family, and for the adoption and child welfare systems. It speaks to a gross failure on many levels.

The Case:
A few days ago Artyom's adoptive mother, Torry Hansen, sent Artyom Savelyev back to his native Russia. Seven year old Artyom had been adopted from a Russian orphanage about one year ago, around the age of six. The story has been featured in every major news outlet in the US and is the subject of great attention and outrage in Russia and throughout the world. Russia has suspended the license of WACAP, the adoption agency.

While the facts we do know, sending the child back to Russia on a plane, are unacceptable, a rush to judgment is also not called for. There is too much we don't know. For example:

What was the nature and quality of the homestudy and what were the qualifications of the provider?

What were Ms. Hansen's expectations and motivations regarding adoption.

What was the content and scope of education Ms. Hansen received regarding adopting an older child, and the potential for various psychological, emotional, and behavioral problems?

Who provided post-placement supervision?

What help did Ms. Hansen seek and from whom?

We do know that Ms. Hansen never brought Artyom to a Psychologist or other mental health professional (This from Ms. Hansen's mother as quoted in an Associate Press article, see for example, page A4 of the Buffalo News or similar material in the April 11, 2010 New York Times). "Hansen said her daughter sought advice from psychologists but never had her adoptive son meet with one." What advice was given?

Did the family seek help from the TN child welfare system, if so what was their response, if not, why not?

This case calls for a thorough and detailed gathering of all the relevant facts, followed by a thorough critical review of what happened and why.

Feb 28, 2010


Assessing Caregiver Reflective Capacity, Commitment, Insightfulness, and Sensitivity is a new DVD by Arthur Becker-Weidman, Ph.D. . This two DVD set provides a comprehensive approach for the assessment of important caregiver functions.

The first DVD begins with an overview of the factors associated with placement stability. The presentation, which includes lecture, PowerPoint slides and videoclips of actual sessions, goes on to present material about assessing parent state of mind with respect to attachment, insightfulness, and reflective abilities.

The second DVD discusses caregiver sensitivity, how to assess commitment, the Adult Attachment Interview, and related topics.

ISBN: 978-0-9822883-3-7.
The DVD can be ordered directly from The Center For Family Development or at

Feb 20, 2010

Temper Dysregulation Disorder & Bipolar Disorder


The proposed DSM-V will contain a new diagnosis, Temper Dysregulation Disorder (TDD). This new category was created to reflect a syndrome that has been labeled childhood bipolar disorder.
The creation of TDD does not deny the existence of bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it is very similar to adult bipolar. TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is not simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.
So what is TDD?
Here is the proposed criteria for TDD: (from the DSM-V site see:
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder. Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.
So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?
1. Lack of continuity to bipolar.
If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009). Instead, these children are more likely to develop depression, not bipolar!
2. Different Biological Markets.
Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008). If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.
3. Different Demographic Factors.
If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.
4. A need for a new category that would impact treatment and research.
In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.
I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.
Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393
Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73
Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71
Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437
Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546
Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54

Feb 17, 2010

Stockholm Syndrome: what it is

In August 2009, when Jaycee Dugard, a woman kidnapped 18 years ago, was found, the media reported that she displayed symptoms of the psychological disorder known as Stockholm Syndrome, so named after a famous Swedish robbery in which hostages sympathized with their captors. Housed in a shed in her captor’s backyard, Dugard was repeatedly raped since she was eleven years old. But when investigators questioned her, Dugard reported that her captor was a “great person.”

Dugard’s case is only one of the many news stories that have received worldwide media attention. The public is fascinated by victims’ seemingly inexplicable positive responses after having suffered physical, emotional, and sexual abuse.

In her groundbreaking book, Loving to Survive: Sexual Terror, Men’s Violence, and Women’s Lives, Dr. Dee Graham, one of the earliest Stockholm Syndrome researchers, identified four characteristics that typify those suffering from the syndrome:

1. Perceived threat to survival, and belief that the captor is able to carry out the threat at any time.
2. A captor carries out a small act of kindness, and the captive perceives it as redemptive.
3. The captive is isolated for a significant amount of time, such that the victim can only see through the captor’s perspective.
4. Perceived impossibility of escape.

Shirley Julich, a professor at the Auckland University of Technology in New Zealand, focuses her research on child sexual abuse. In 2005, she wrote a comprehensive report analyzing interviews with 21 survivors of childhood sexual abuse. In her attempt to understand her interviewers’ initial reticence to report abuse, she turned to Graham’s research, concluding that Stockholm Syndrome was indeed a major culprit, in effect contradicting an earlier child sexual abuse study conducted by the Otago Women’s Health Survey.

Shirley Julich’s full report is available here.

To read a more in-depth description of Stockholm Syndrome symptoms, read Dr. Joseph Carver’s Mental Health Matters blog post .

To get a brief history of major news stories featuring victims suffering from Stockholm Syndrome, read this recent Time magazine article.

Feb 14, 2010

Overview of Proposed DSM-V Changes


There are no proposed changes to the diagnosis of Reactive Attachment Disorder. In addition, the proposals to add Developmental Trauma Disorder of Complex Trauma have been rejected, which is most unfortunate. Many children who have experienced chronic early maltreatment within a caregiving relationship exhibit a range of symptoms across several domains. Without a diagnostic category of Developmental Trauma Disorder that captures the range and depth of dysfunction, we are left giving children a basket of different diagnoses. This can lead to treating a range of symptoms and not the underlying causative factors.

There are substantial changes proposed for the Diagnostic and Statistical Manual of Mental Disorders.
The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site,, to obtain comments.
A few of the proposed major changes:
• Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"
• Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category
• Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex
• Offering a new assessment tool for suicide risk
• Including a category of "risk syndromes" for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do
• Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage
• Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia
• Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories
The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned.
New Categories for Dyslexia, Autism
In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.
Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.
The head of the APA's work group on substance-related disorders, Charles O'Brien, MD, PhD, of the University of Pennsylvania, told reporters on a press call that substance dependence and abuse had no basis in the research on addictions.
"We unanimously agreed that . . . there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.
He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers. The draft, DSM-V will include "discontinuation syndromes" to allow for the proper assessment of symptoms of withdrawal from psychoactive substances, including caffeine.
Dimensional and Risk Assessments
There are two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults. The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness. In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.
Temper Dysregulation Disorder to be used in some cases instead of Bipolar Disorder
There is a proposed new diagnosis. The proposed new childhood disorder, temper dysregulation with dysphoria (TDD). It is reported that about 40% to 60% of the cases seen will be children who are doing things that other people don't want them to do. Many of these are children who are "stubborn and resistant and disobedient and moody, according to David Shaffer, MD, of Columbia University. There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness.
Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults, according to Dr. Shaffer. He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.
Dimensional Assessment
Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.
Gender Identity Disorder Stays
A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. In the draft, APA leaders are proposing to rename the condition "gender incongruence" for adults and children.
People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.
At the APA's annual meeting last May, members of the transgender community made a case for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.
APA officials said the organization planned more discussions with members of the transgender community.
Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.
Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

Feb 3, 2010

How does Attachment Develop?

The attachment system evolved over time to ensure the survival of the infant. The attachment system is a biologically based system found in nearly all mammals. The attachment system operates in a manner similar to your home heating and cooling system. If the temperature is just right, nothing happens. Only when the temperature goes outside of preset bounds does your heating and cooling system turn on. The same type “homeostatic” process is at the core of the attachment system.
In its most simple form, the attachment system is a proximity seeking system. When the child feels some threat, the child gravitates toward the preferred caregiver, who is most likely to care for and protect the child. This is how the attachment system evolved as a means of ensuring the survival of the vulnerable infant and child. The attachment system and the exploration system operate like a see-saw. If one is activated, the other is deactivated. When the child feels safe and secure, the exploration system is active. When threatened, fearful, anxious, the attachment system is active.
Attachment behavior, which is proximity seeking behavior, is exhibited throughout the life cycle. The toddler, when threatened, will go to the parent, maybe grab the parent’s leg, hide behind the parent, or in some other way make contact with the parent. Once the child feels safe, the child will then go about exploring the environment (playing). An example of attachment behavior in a young adult can be seen in the actions of a young student away at college on 9/ll 2001. On that day the student called home several times during the day to give her parents “news updates” about the unfolding events. Her first call was to, “turn on the TV Dad, a plane just hit the world trade center.” Her second call was, “Mom, did you see, a second plane hit….” And so it went throughout that awful day. Something terrible was happening that was a threat to the girl, and so she felt the need to make contact with her primary attachment figures. For a young adult, the telephone worked fine; while for a toddler, physical contract may be necessary.
So, then, how does this system develop? Remember Erik Erikson’s stages of development? The first stage, Trust vs. Mistrust? During this stage the foundation of attachment and patterns of attachment emerge. Infants cannot easily regulate themselves and they need a caregiver to regulate them. The normally sensitive parent responds to the child’s cries, figures out what is wrong, and then responds to meet the need. When this happens is a fairly regular and consistent manner the child learns, experientially, several important things. The child learns that the world is largely a benign place. The child learns that discomfort will be remedied before it gets too bad; this forms the basis for impulse control. The child learns that its needs will be met in a timely manner. The infant learns that caregivers are largely reliable, good, and helpful. And the child learns that the child is valued, valuable, loved, and loveable.
During the toddler years, which are about shame, the child is ambulatory, exploring the world, and “getting into trouble,” largely because the child does not recognize dangers. As a result, the caring parent is saying “NO!” a lot; to protect the child. When the parent sets this sort of limit, the child experiences shame. The child may cry, hide, cover the child’s face, or in some other manner evidence shame. Shame is about who you are and when we feel shame, we hide. The normally sensitive parent responds by comforting the child while setting the limit. “It’s ok, sweetie, I don’t want you to grab that cup because it is very hot and you could hurt yourself.” The child looks at the parent, experiences that the parent is not angry at the child, and then the parent repairs the relationship and reconnects with the child. When this happens repeatedly, the child moves from shame to guilt. The child learns, experientially, that while the child is loved and loveable, it is what the child does, not the child, that is upsetting the parent. Guilt is about what you do; shame is about who you are. When you feel shame you hide; when you feel guilt you want to confess and fix it.

Feb 1, 2010

Finding homes for Children in Foster Care

A recent article in the NY Times describes the efforts of one man to track down the relatives of children in foster care and to help children move into permanent adoptive homes. His work is quite inspiring. Mr. Lopez, a former police detective, now does gumshoe work for what he calls a more fulfilling cause: tracking down long-lost relatives of teenagers languishing in foster care, in desperate need of family ties and in danger of becoming rootless adults.

"Finding an adoptive parent for older children with years in foster care is known in child welfare circles as the toughest challenge. Typically, their biological parents abused or neglected them and had parental rights terminated. Relatives may not know where the children are, or even that they exist. And the supply of saints in the general public, willing to adopt teenagers shaken by years of trauma and loss, is limited."

This is an inspiring article.

The article can be found at:


Jan 29, 2010

New book for parents

Attachment Parenting, a new book edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, will be out in May of this year. Many of the chapters are written by myself and Deb. In addition, there are a number of chapters by various experts in the fields of Theraplay, Sensory-Integration, and Neuropsychology. The book is for parents and professionals and provides a home-based approach for parents to use to help children with complex trauma and disorders of attachment. The book is grounded in Dyadic Developmental Psychotherapy, which is an evidence-based, effective, and empirically validated treatment.

Jan 6, 2010

Treatment for PTSD

Post Traumatic Stress Disorder (PTSD) is quite different from Complex Trauma. PTSD is a clinical diagnosis usually applied when an person has experienced a life-threatening event and develops certain symptoms. Complex Trauma refers to the pervasive effects of chronic early maltreatment within a care-giving relationship. Complex Trauma usually results in more impairments that does PTSD.

Dyadic Developmental Psychotherapy is an evidence-based, effective, and empirically validated treatment for Complex Trauma.

Post-traumatic stress disorder (PTSD) is characterized by symptoms such as repeated, intrusive upsetting memories of the trauma; avoidance of similar situations and things which might remind one of them; a feeling of detachment from others; hypervigilance, and overarousal. It is associated with problems at work and at home and it is estimated that between 1% and 14% of people might suffer from it over the course of their lifetime. A team of researchers from New York reviewed 57 studies into treatments for PTSD and acute stress disorder which can often lead to it. They found that there was the strongest evidence for trauma-focused cognitive-behavioural therapy (CBT) and eye-movement desensitization and reprocessing (EMDR). There was some evidence that stress innoculation training, hypnotherapy, interpersonal psychotherapy and psychodynamic psychotherapy were effective for PTSD and that trauma-focused CBT was effective for acute stress disorder. The study also found evidence that trauma-focused CBT was effective for assault- and road-traffic-accident-related PTSD.

Ponniah, Kathryn and Hollon, Steven D. - Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review Depression and Anxiety December 2009, 26(12), 1086-1109