Child and Adolescent Psychiatry Consulting, LLC Jenna Saul, M.D. F.A.A.C.A.P.  (715) 318-0047 

Ashley Judd Slaps Media in the Face for Speculation Over Her ‘Puffy’ Appearance

THIS EDITORIAL first appeared at The Daily Beast at http://www.thedailybeast.com/articles/2012/04/09/ashley-judd-slaps-media-in-the-face-for-speculation-over-her-puffy-appearance.html

editorial@thedailybeast.com.

Ashley Judd’s ‘puffy’ appearance sparked a viral media frenzy. But, the actress writes, the conversation is really a misogynistic assault on all women.

The Conversation about women’s bodies exists largely outside of us, while it is also directed at (and marketed to) us, and used to define and control us. The Conversation about women happens everywhere, publicly and privately. We are described and detailed, our faces and bodies analyzed and picked apart, our worth ascertained and ascribed based on the reduction of personhood to simple physical objectification. Our voices, our personhood, our potential, and our accomplishments are regularly minimized and muted.

As an actor and woman who, at times, avails herself of the media, I am painfully aware of the conversation about women’s bodies, and it frequently migrates to my own body. I know this, even though my personal practice is to ignore what is written about me. I do not, for example, read interviews I do with news outlets. I hold that it is none of my business what people think of me. I arrived at this belief after first, when I began working as an actor 18 years ago, reading everything. I evolved into selecting only the “good” pieces to read. Over time, I matured into the understanding that good and bad are equally fanciful interpretations. I do not want to give my power, my self-esteem, or my autonomy, to any person, place, or thing outside myself. I thus abstain from all media about myself. The only thing that matters is how I feel about myself, my personal integrity, and my relationship with my Creator. Of course, it’s wonderful to be held in esteem and fond regard by family, friends, and community, but a central part of my spiritual practice is letting go of otheration. And casting one’s lot with the public is dangerous and self-destructive, and I value myself too much to do that.

However, the recent speculation and accusations in March feel different, and my colleagues and friends encouraged me to know what was being said. Consequently, I choose to address it because the conversation was pointedly nasty, gendered, and misogynistic and embodies what all girls and women in our culture, to a greater or lesser degree, endure every day, in ways both outrageous and subtle. The assault on our body image, the hypersexualization of girls and women and subsequent degradation of our sexuality as we walk through the decades, and the general incessant objectification is what this conversation allegedly about my face is really about.

A brief analysis demonstrates that the following “conclusions” were all made on the exact same day, March 20, about the exact same woman (me), looking the exact same way, based on the exact same television appearance. The following examples are real, and come from a variety of (so-called!) legitimate news outlets (such as HuffPo, MSNBC, etc.), tabloid press, and social media:

One: When I am sick for more than a month and on medication (multiple rounds of steroids), the accusation is that because my face looks puffy, I have “clearly had work done,” with otherwise credible reporters with great bravo “identifying” precisely the procedures I allegedly have had done.

Two: When my skin is nearly flawless, and at age 43, I do not yet have visible wrinkles that can be seen on television, I have had “work done,” with media outlets bolstered by consulting with plastic surgeons I have never met who “conclude” what procedures I have “clearly” had. (Notice that this is a “back-handed compliment,” too—I look so good! It simply cannot possibly be real!)

Three: When my 2012 face looks different than it did when I filmed Double Jeopardy in 1998, I am accused of having “messed up” my face (polite language here, the F word is being used more often), with a passionate lament that “Ashley has lost her familiar beauty audiences loved her for.”

Four: When I have gained weight, going from my usual size two/four to a six/eight after a lazy six months of not exercising, and that weight gain shows in my face and arms, I am a “cow” and a “pig” and I “better watch out” because my husband “is looking for his second wife.” (Did you catch how this one engenders competition and fear between women? How it also suggests that my husband values me based only on my physical appearance? Classic sexism. We won’t even address how extraordinary it is that a size eight would be heckled as “fat.”)

Ashley Judd on her new show “Missing”

Five: In perhaps the coup de grace, when I am acting in a dramatic scene in Missing—the plot stating I am emotionally distressed and have been awake and on the run for days—viewers remarks ranged from “What the f–k did she do to her face?” to cautionary gloating, “Ladies, look at the work!” Footage from “Missing” obviously dates prior to March, and the remarks about how I look while playing a character powerfully illustrate the contagious and vicious nature of the conversation. The accusations and lies, introduced to the public, now apply to me as a woman across space and time; to me as any woman and to me as every woman.

That women are joining in the ongoing disassembling of my appearance is salient. Patriarchy is not men. Patriarchy is a system in which both women and men participate. It privileges, inter alia, the interests of boys and men over the bodily integrity, autonomy, and dignity of girls and women. It is subtle, insidious, and never more dangerous than when women passionately deny that they themselves are engaging in it. This abnormal obsession with women’s faces and bodies has become so normal that we (I include myself at times—I absolutely fall for it still) have internalized patriarchy almost seamlessly. We are unable at times to identify ourselves as our own denigrating abusers, or as abusing other girls and women.

A case in point is that this conversation was initially promulgated largely by women; a sad and disturbing fact. (That they are professional friends of mine, and know my character and values, is an additional betrayal.)

That the conversation about my face was initially promulgated largely by women is a sad and disturbing fact.

News outlets with whom I do serious work, such as publishing op-eds about preventing HIV, empowering poor youth worldwide, and conflict mineral mining in Democratic Republic of Congo, all ran this “story” without checking with my office first for verification, or offering me the dignity of the opportunity to comment. It’s an indictment of them that they would even consider the content printable, and that they, too, without using time-honored journalistic standards, would perpetuate with un-edifying delight such blatantly gendered, ageist, and mean-spirited content.

Ashley Judd responds to her critics on ‘Nightly News.’

I hope the sharing of my thoughts can generate a new conversation: Why was a puffy face cause for such a conversation in the first place? How, and why, did people participate? If not in the conversation about me, in parallel ones about women in your sphere? What is the gloating about? What is the condemnation about? What is the self-righteous alleged “all knowing” stance of the media about? How does this symbolize constraints on girls and women, and encroach on our right to be simply as we are, at any given moment? How can we as individuals in our private lives make adjustments that support us in shedding unconscious actions, internalized beliefs, and fears about our worthiness, that perpetuate such meanness? What can we do as families, as groups of friends? Is what girls and women can do different from what boys and men can do? What does this have to do with how women are treated in the workplace?

I ask especially how we can leverage strong female-to-female alliances to confront and change that there is no winning here as women. It doesn’t actually matter if we are aging naturally, or resorting to surgical assistance. We experience brutal criticism. The dialogue is constructed so that our bodies are a source of speculation, ridicule, and invalidation, as if they belong to others—and in my case, to the actual public. (I am also aware that inevitably some will comment that because I am a creative person, I have abdicated my right to a distinction between my public and private selves, an additional, albeit related, track of highly distorted thinking that will have to be addressed at another time).

If this conversation about me is going to be had, I will do my part to insist that it is a feminist one, because it has been misogynistic from the start. Who makes the fantastic leap from being sick, or gaining some weight over the winter, to a conclusion of plastic surgery? Our culture, that’s who. The insanity has to stop, because as focused on me as it appears to have been, it is about all girls and women. In fact, it’s about boys and men, too, who are equally objectified and ridiculed, according to heteronormative definitions of masculinity that deny the full and dynamic range of their personhood. It affects each and every one of us, in multiple and nefarious ways: our self-image, how we show up in our relationships and at work, our sense of our worth, value, and potential as human beings. Join in—and help change—the Conversation.

• Ashley Judd is a prolific actress, who will next be seen in ABC’s new midseason show, Missing. Judd most recently appeared in Dolphin Tale alongside Morgan Freeman, Harry Connick Jr. and Kris Kristofferson.
• Judd is also on the board of directors for PSI (Population Services International), which she joined in 2004 after serving as Global Ambassador for PSI’s HIV education and prevention program, YouthAIDS since 2002.  Judd has visited PSI programs in Thailand, Cambodia, Madagascar, Kenya, South Africa, Guatemala, Honduras, Nicaragua, El Salvador, India, Rwanda and the Democratic Republic of Congo. In her work, she witnesses the lives of the exploited and poor to help educated the world about the reality of global poverty and bring solutions to the devastating effects of social injustice and gender inequality.
• Judd was the subject of three award-winning documentaries aired in more than 150 countries worldwide on VH1, The Discovery Channel and The National Geographic Channel.  In her role as PSI board member, Judd has graced the covers of countless magazines and been the subject of newspaper and television interviews bringing vital awareness to issues closest to her heart, gender inequality and poverty alleviation.
• Judd has visited legislators on Capitol Hill, addressed the General Assembly of the UN on the scourge human trafficking, spoke at the National Press Club, testified before the Senate Foreign Relations Committee for the protection of vulnerable women from violence, sexual abuse and HIV and, most recently served as an expert panelist at Clinton Global Initiative to discuss the issue of safe water and the empowerment of girls in the developing world.
• Recently, Judd has come on board as a spokesperson for organizations Defenders for Wildlife and The Sierra Club providing her time and voice to advocate against practices of aerial wolf hunting (Defenders for Wildlife) and mountaintop removal coal mining (The Sierra Club).
• She resides in Tennessee and Scotland with her husband, the international racing star Dario Franchitti.  They have 8 beloved pets and enjoy a quiet, rural life.

This article first appeared in the Bradenton Herald

Lisa S. Kantor: An Open Letter to Dr. Oz

By Lisa S. Kantor

Posted: 7:53pm on Mar 19, 2012; Modified: 7:58pm on Mar 19, 2012

LOS ANGELES, March 19, 2012 — /PRNewswire/ — Along with countless professionals and families dealing with the physical, emotional and financial consequences of eating disorders, I am deeply disturbed by the way your recent program, “Dying to Be Thin: Meet the Skinniest Women in America,” had the unintended effect of glamorizing the deadliest of all mental illnesses. Rather than documenting the tragedy associated with eating disorders and providing encouragement to sufferers to seek help, you perpetuated myths about the disease and provided harmful information to millions. I believe this show did more harm than good. As a physician, you have a responsibility to improve your coverage of eating disorders in future shows.

“Dying to Be Thin,” while tantalizing, serves to perpetuate one of the deadliest misconceptions about eating disorders. People with eating disorders are not necessarily “skinny” or “thin,” and certainly not everyone who dies from an eating disorder is underweight. In fact, many people die at a very normal weight, especially if they have bulimia. You mentioned on your show that the “more acute cases” were the “thinner” women. That myth is also dangerous to disseminate. Those who weigh less than others are not necessarily “more acute” than others at a “healthy weight.” That misconception has long created stigmas associated with eating disorder sufferers and has often led to under-treatment by physicians who think that because a woman is not thin, she is not as acute. Your focus on thinness did a grave disservice by failing to educate your audience scientifically about what eating disorders really look like.

In giving air time to the Pro-Ana movement, you referred to it as “a dangerous new trend that helps women be skinny at any cost.” The Pro-Ana movement is not new. Pro-Ana (and Pro-Mia) sites have been around since the dawn of the Internet. Far from being “trendy,” they are a very dangerous facet of an eating disorder underground that preys on the mentally ill. Had you consulted an eating disorders expert, you would never have offered your audience direct access to the websites and their images. Studies show that doing so causes harm. One study, on college-aged women (none of whom had eating disorders), discovered that after viewing pro-eating disorders websites, 84% reduced their calorie intake by more than 2,000 calories per week. Only 56% of the women realized they were eating less. Results of the study also indicated that the women exposed to the pro-eating disorders website had decreases in self-esteem and perceived attractiveness.

My days are spent in and out of federal courts battling insurance companies that deny benefits for seriously ill women and men who seek adequate treatment for their diseases – even though a federal law and many state laws mandate that insurers provide similar levels of treatment for mental illnesses as they provide for physical illnesses.  Shows such as the one you aired trivialize this disease and undermine the progress well-respected groups such as the International Association for Eating Disorders Professionals, the Eating Disorders Coalition, the National Eating Disorders Association, and the Binge Eating Disorder Association have achieved. Still, getting the national media to take eating disorders seriously without parading dangerously thin women across the television screen is about as difficult as getting an insurance company to pay for a therapeutic length of stay at a residential treatment facility.

It is hard for me to believe that either you or your staff did any legitimate research about eating disorders before planning the programs. Were you aware that professionals in the eating disorder field were in touch with producers at your show in recent months offering the benefits of their expertise free of charge should you plan to air segments about eating disorders? Those calls and e-mails appear to have been ignored.

You owe it to your many viewers to correct the harm your recent program caused. First, please remove all material from your website and blog that mentions the Pro-Ana movement. Second, work with some of the many excellent professionals at reputable facilities around the country to plan follow up segments to properly educate your audience about how people can recover from eating disorders and lead productive and fulfilled lives not centered on food. You have an opportunity to teach millions across the country, including other physicians who might watch your show, the real skinny about eating disorders. I hope you will do the right thing.

About Lisa S. Kantor

Lisa S. Kantor, a Los Angeles lawyer and member of the Board of Directors of the Eating Disorders Coalition, is the country’s premier legal advocate for patients with eating disorders who have been denied health insurance benefits for treatment.  In 2011, the 9th U.S. Circuit Court of Appeals ruled for her client in Harlick v. Blue Shield, creating one of the most influential decisions ever in mental health parity litigation and paving the way to making treatment and recovery for severe mental illnesses more attainable.  For more information, go to www.kantorlaw.net.

SOURCE Lisa S. Kantor

Melissa Avrin, 16, in the summer of 2006.

ANDREW AVRIN sits on a beige couch in a nondescript room, a fruit still-life partly visible on the wall behind him, twisting his fingers while, off-camera, an unseen interviewer prompts him to talk about his sister, Melissa, who died last year at the age of 19 after a long battle with bulimia.

“There was no food in the house,” he says, looking off to the side as his eyes fill. “If I went out with friends, I could not bring leftovers home because they would be gone by the next morning.”

Once, he explains, in the middle of a bitterly cold night, he looked out the window and saw Melissa on the curb, going through the garbage. “I went outside and I yelled her name,” he recounts in the interview, his voice breaking. “Just the way she looked back at me — it was so empty, vacant. It was a deer in the headlights, but that doesn’t even explain it.”

It is a hard scene for anyone to watch, but even more so for the film’s producer — Judy Avrin, Melissa’s mother, who decided to make a documentary about her daughter’s life and, ultimately, her death.

People deal with grief in their own ways, and those who have been spared the loss of a daughter or a son can only imagine how they would choose to try to cope. For Ms. Avrin, coping meant confronting her anguish and trying to make something good come out of it.

The idea for a film didn’t occur to her immediately. In the weeks following Melissa’s death, Ms. Avrin mostly avoided her daughter’s bedroom, and tried to resume some semblance of normalcy, going back to work three days a week as the coordinator for a consortium of academic libraries in New Jersey. But one day she sat down to read Melissa’s leather-bound journal.

Someday …

I’ll eat breakfast.

I’ll keep a job for more than 3 weeks.

I’ll have a boyfriend for more than 10 days.

I’ll love someone.

I’ll travel wherever I want.

I’ll make my family proud.

I’ll make a movie that changes lives.

The film, called “Someday Melissa” and now in the editing stages, has become for Ms. Avrin salve, distraction and cause — a way to get the word out to other families grappling with eating disorders that they are not alone; to sound the alarm that eating disorders have the highest mortality rate of any mental illness; to help make sense of the senseless event that was losing her teenage daughter.

“I kept saying, ‘This is an amazing way for me to channel my grief,’ ” Ms. Avrin said. “But it also allowed me to put off grieving.”

Ms. Avrin, 56, got the idea for the film from one of Melissa’s therapists, Danna Markson, who introduced her to Jeffrey Cobelli, 27, a filmmaker. Over the last several months of working on the project, Ms. Avrin has come to know more than she ever intended to about eating disorders — how their seriousness has been underestimated, their treatment underinsured, their deaths underreported.

The process hasn’t been easy, and some, like her ex-husband, initially questioned the impulse to do it at all. Melissa’s best friend since first grade, Nicole Kendrick, who also suffers from an eating disorder, said she was incredulous when she first learned that Ms. Avrin was making the film. “I thought she was crazy,” Ms. Kendrick said. “I guess I didn’t realize how deep a mother’s love can run.”

But Ms. Avrin said that making the film has been easier than doing nothing at all. “I’ve never once thought this was more than I could bear,” she said, in an interview at her home in Totowa, N.J. “If anything, the more I continue, the more I know it’s the right thing to do.”

The difficulty of reliving her daughter’s decline has been mitigated by the public response. “Sometimes I think: ‘I’m a suburban mom. Who am I to think I could make a difference in the world?’ ” Ms. Avrin said. “But then I read the messages that keep coming in from people I know and people I don’t know who say Melissa’s story has motivated them to fight one more day.”

On Melissa’s Facebook page and on the film’s Web site — somedaymelissa.com — Ms. Avrin continues to get feedback. “Thank you,” says one entry posted on the Web site’s guestbook page. “This could save one person’s life. That life may be mine.”

Ms. Avrin and Mr. Cobelli have interviewed Melissa’s family members, doctors and friends, along with prominent experts in the field, like Dr. Thomas R. Insel, the director of the National Institute of Mental Health; and Dr. B. Timothy Walsh, the founding director of the Eating Disorders Research Unit at the New York State Psychiatric Institute, and Dr. Evelyn Attia, the director of the Columbia Center for Eating Disorders, both at Columbia University Medical Center.

“I get a lot of requests, but there was something about this one I thought was particularly striking,” said Dr. Insel of the mental health institute. “I wanted to hear more of the story.”

“It was such an extraordinary expression of love,” he said, “a powerful way of honoring and remembering the daughter she lost.”

Although those closest to Melissa agreed to be interviewed for the film, participating wasn’t easy. William Avrin, Melissa’s father, said that he might have preferred to keep his experience to himself and that he was in no hurry to revisit his memories of Melissa. “I have a hole in my heart and it will be there forever,” he said in a telephone interview. “I don’t really try to describe what it’s like to lose a child.”

But he felt he had to do it for the film. “Clearly, Judy’s a champion of this project,” he said. “I’m a little bit more personal and inward. I’m still struggling with the whole thing. This is her way of dealing with it, and I respect that.”

In the documentary interview, filmed at his home in Hamburg, N.J., Mr. Avrin visibly struggles to describe what it was like to be thousands of miles away in Japan on business when he found out his daughter had died. At first he appears almost devoid of emotion, delivering his words in flat, deliberative sentences as he sits in a blue button-down shirt in front of his fireplace mantel. But then you can see tears trickling down into his salt-and-pepper mustache. “What was I thinking?” he says, repeating the question. “I was thinking my daughter is dead. That’s not supposed to happen. I couldn’t believe it. I didn’t — didn’t know what to think. I was in shock.”

Upon returning from Japan, Mr. Avrin decided not to view his daughter’s body. “Judy thought it would be better if I didn’t,” he said, “that I’d remember her like the last time that I saw her.”

Melissa died on May 6, 2009. Cause of death: heart attack due to complications from an eating disorder. Just a few days before, Melissa learned she had been admitted to Emerson College. The official letter of acceptance arrived a week after she died and sits unopened.

Melissa’s brother, Andrew, who is completing his Master of Science degree in engineering, said he believes the documentary has become essential to his mother’s emotional resilience. “It’s the only way she knows how to move forward,” he said.

At the same time, Andrew said he worried that the documentary would ultimately prove to be just a Band-Aid, postponing the heartbreak that is bound to rear its head when the film is completed. “The trick becomes moving forward with life but not letting everything this project is fill the void completely,” he said, “so the second this project finishes, you don’t crash.”

To be sure, Ms. Avrin doesn’t always hold it together. She did not conduct the interviews with her ex-husband or with her son (her collaborator, Mr. Cobelli, did). “We would have just sat there and cried,” she said.

In the interviews she did do, there have been times when she has broken down during or afterward. In concluding her discussion with Dr. Leslie Sanders, one of Melissa’s doctors, for example, Ms. Avrin starts to cry, and the cameras keep rolling. “I still remember being in your office and — I think her potassium was off — and you said, ‘I’ll be your quarterback,’ ” Ms. Avrin tells Dr. Sanders. “I didn’t know who to turn to next and I felt like I was in such good hands with you.”

Dr. Sanders responds: “I think what I remember about that first visit is just being struck at how little her life had become — I think at that point she was barely in school — and how much she was struggling, not just physically, I think physically was the least of it, but just emotionally and how we needed to do something intensive, and quickly, to get her life back.”

BORN Dec. 21, 1989, Melissa seemed in her early years to be a happy little girl. Her family lived in Wayne, N.J., and then in Pine Brook, N.J., spending two years in Coral Gables, Fla., in between, where Mr. Avrin was transferred for his work with a specialty chemical company. Melissa did well in school — producing A’s and short stories.

But at age 13, thing started to change. Melissa’s mood darkened; she didn’t want to go to school or do extracurricular activities. She developed stomach problems and constipation. Ms. Avrin took her to a pediatric gastroenterologist who said Melissa probably had an eating disorder. “I reacted the way most parents do: ‘That’s not possible,’ ” Ms. Avrin said. “We didn’t go back to him.”

In the early stages, the Avrins did not really see what was going on, in part because Melissa wasn’t visibly underweight, in part because they didn’t want to. But clues started to show up that were too stark to ignore — logs of cookie dough that disappeared from the freezer along with whole boxes of cookies from the cabinet. Empty pizza boxes. “I found containers with chewed and spit-out food and I’d never heard of that before,” Ms. Avrin tells Dr. Sanders during their filmed interview. “Is that very common?”

Ms. Avrin wrapped the fridge in locks and chains, hid her purse and made sure never to leave money lying around. “It didn’t have to be good junk food — if she wanted to go on a binge, it could be a dozen eggs,” Ms. Avrin said of Melissa. “Anything that wasn’t nailed down, she would eat.”

Ms. Kendrick, in her own interview for the film, alternates between smiling recollections of her childhood friend and sad eyes as she recalls Melissa’s downward spiral. “People who knew her in the last two years never really saw who she really was,” she says. “She was so energetic and funny and just ridiculous but not, like, in an obnoxious way. And then, as she started to worry about what other people thought, that’s when it started to be in more of an attention-getting way. When things got really bad, that kind of all just slowly disappeared and it just became very monotone — down. And we didn’t really see that energetic, fun Melissa anymore.”

Eventually, Melissa was sent away for professional help against her will and thus began a series of programs over the next few years that had varying degrees of success. It wasn’t until Melissa’s third round of in-patient treatment — when she and other young women testified about their eating disorders in front of their families — that her father began to fully understand. “I really said, ‘Wow this is almost like heroin addiction,’ ” he says in his film interview. “They need to purge because it makes them feel high and it’s something they need to do. I never appreciated that.”

In the course of making the film, Ms. Avrin has become something of a public service announcement on eating disorders. She was a featured speaker last October at the first walk to raise money for the National Eating Disorders Association. At its benefit dinner in March in New York, the evening opened with a clip from Ms. Avrin’s film. She is due to be in Washington in late April to lobby Congress as part of an Eating Disorders Coalition.

She said she is happy to play the role of advocate, to help try to remove the stigma that still cloaks eating disorders and keeps people from acknowledging the disease as the cause of death in obituaries. “I want it to come out of the shadows,” Ms. Avrin said. “I want people to talk about it, for people to get treatment faster, to reach doctors on the front lines. I want parents to open their eyes and not be swayed by being glad that their kid fits into size 4 jeans — to stop focusing on looks.”

Ms. Avrin is aiming to finish her documentary project by June, in time for summer film festival deadlines, and she said she is determined to get theatrical distribution. It would seem the ultimate act of acceptance. Yet in her film interview with Dr. Sanders, Ms. Avrin sounds like a mother still wrestling with remnants of denial.

“I’ve always been the glass half-full — I’ve always been an optimist,” she says, reaching under her eyeglasses to wipe away tears. “I always believed that she really would be somebody who could recover, even though, looking back, I realized the odds were stacked against her because of the level of her illness.”

“But I never lost hope and, you know,” she adds, “I still believe that she could have beaten it.”

In May 17, 2010, the U.S. Supreme Court ruled on Graham v. Florida that sentencing Florida juveniles to life in prison without parole for crimes less than murder was unconstitutional.  Graham v. Florida was the first time the court had applied the 8th Amendment’s prohibition against “cruel and unusual punishment” to anything other than the death penalty. In its ruling, the Supreme Court declared that juveniles were ineligible for life without parole because they were different than adults who committed the same crime. They were not yet fully developed human beings mentally, emotionally and physiologically. The parts of the teenage brain that rule impulse, the ability to think ahead, the understanding of consequences, is not yet fully formed.

The justices made a distinction between teens who commit crimes as part of their “transient immaturity” and those who are permanently “incorrigible.” The decision as to whether a juvenile criminal is one or the other can’t be made while they are still teenagers, but it can be determined after they’ve fully matured, the court said in its 6-3 ruling.

The court’s ruling meant juveniles who were sentenced to life without parole for crimes such as armed robbery, assault, rape and attempted murder needed to be resentenced. Of the dozens of juveniles serving life sentences in the United States at the time of the Graham decision, more than half of them were in Florida.

Barry University law professor, Gerry Glynn, established the Juvenile Life Without Parole Defense Resource Center  in June 2010,  to coordinate efforts to represent the Florida inmates who were sentenced as juveniles to life without parole.  There are 115 cases of juveniles sentenced to life in Florida, and the cases are extremely complex.

In preparing for a resentencing hearing, the defense resource center must help attorneys tell judges about three important aspects of the inmate: the life of the juvenile before the crime, the crime itself and the inmate’s life behind bars.Attorneys must be able to show the dangerous juvenile who committed the crime has changed inside prison into a mature, reformed adult. They must explain why the juvenile committed the crime and why that same person, years later, is no longer a threat to society

Juveniles convicted of serious crimes must be given a “second look” after they have achieved full maturity to determine whether they have outgrown the impulsive, thoughtless, risky behavior typical of teenagers — or whether they remain dangers to society. One way to determine whether that change has taken place, the court ruled, is to see whether juvenile inmates took advantage of education, vocational and rehabilitative opportunities while in prison. However, the problem for inmates sentenced to life in Florida is that they do not have access to educational and vocational programs, since the Department of Corrections gives priority to those inmates who are within 3 years of being released.

There aresome inmates who, having  no chance of release, have engaged in self-motivated rehabilitation. For example, a  41-year-old Hillsborough inmate sentenced to life without parole at 17 for attempted murder and sexual battery in 1989 has completed 20 self-improvement programs, including three he created himself.

Gainesville State Attorney Bill Cervone argues that the relatively small number of juveniles sentenced to life without parole reflects the atrocity of their crimes and their continued threat to public safety. He believes that the crimes they committed are very serious  and that these behaviors indicate the risk they pose to the community.

Those who support the Supreme Court decision agree that there are people in prison who committed crimes at 16 who will continue to be a danger to society later, but that each youth deserves the chance to be evaluated.

Thus far,  a handful of Graham-eligible inmates have been resentenced under the court’s ruling, and none has been released from prison. The resentences vary from 30 years to 107 years. No one has been resentenced yet in Central Florida courts, but among those who are eligible is Michael S. Johnson, who was 16 in 2005 when he and two others kidnapped, robbed and raped two women.

In a similar case in St. Petersburg, Jose Walle was 13 when he participated with two others in the kidnapping, robbing and raping of two waitresses. In November 2010, Walle was resentenced to 65 years by a judge who rejected the Supreme Court’s opinion that life without parole for juveniles was cruel and unusual.  Walle, now 16, will begin serving his 65 year sentence after completing 27 years for another Pinellas County rape. Under the consecutive sentences, Walle will be eligible for release when he is 91. His attorneys say they will appeal the sentence as violating the intent of the Graham decision.

Read more in the article by Jeff Kunerth, Orlando Sentinel

orlandosentinel.com/news/local/crime/os-life-without-parole-barry-20110402,0,5418922.story

Attorney General Eric Holder  Spoke at the National Association of Counties Legislative Conference in Washington, D.C. ~ Monday, March 7, 2011

He noted that the Association of Counties, and the Department of Justice have common goals, of doing more and more to serve our citizens while resources diminish. He identified two specific priorities for the Justice Department:

“how we can improve the effectiveness of our juvenile justice system, and how we’re going to ensure that every American can access the legal services they need and deserve.”

He noted that “one of the most important lessons I learned as a federal prosecutor, as a judge, as a United States Attorney, as Deputy Attorney General, as Attorney General – and, above all, as a father of three children: that the work of protecting, assisting, and empowering our young people could not be more urgent.   “

He noted that:

• The nation’s juvenile justice system is in need of change, that it doesn’t spend resources as wisely as it should, and does not improve as many lives as it could.

• Although African-American youth make up 16 percent of the overall youth population, they make up more than half of the juvenile population arrested for committing a violent crime.

• Abused and neglected children are 11 times more likely than their non-abused and non-neglected peers to be arrested for criminal behavior.

• That so many of those who enter our juvenile justice system either can’t afford – or do not know to ask for – access to legal guidance.

• Some youth even plead guilty to criminal offenses without the advice of a lawyer.

• Even though many of those who are incarcerated enter the juvenile justice system for non-violent offences, they often emerge violent – or, at the very least – traumatized.

• A scientific review of nine “Scared Straight” programs around the country showed that children ordered into these programs are nearly 30 percent more likely to offend than youths who are not.

• In another study, 12 percent of the adjudicated youth in state-operated and large locally or privately operated juvenile facilities reported experiencing at least one incident of sexual victimization while incarcerated.

“A recent Utah Youth Suicide Study reported that young victims of suicide had nearly a seven in ten chance of an association with the juvenile justice system, calling us to question whether the current system is improving lives – or devastating them.”

TRANSITIONING OUT OF JUVENILE JUSTICE

• Each year, 100,000 young people exit formal custody.   And some of them have nowhere to go.   Too many of these young people return to unstable homes – or end up in shelters, on the streets, or in other potentially dangerous, or violent, situations.   And many are not welcomed back to their community school and struggle to find educational opportunities.
• Within a year of reentry, one study found that only 30 percent of previously incarcerated youth are involved in either school or work.   The unfortunate fact is that many end up in our jails and prisons.

Robert Kennedy believed that the link between justice and children could never be broken without compromising our founding ideals – and our most sacred principles.   He was right.

Mr. Holder noted that justice in the juvenile system is a moral issue that makes good fiscal sense:

• “How we treat our children answers the question of who we are as a nation.”
• “Better serving our young people makes good economic sense by keeping them out of over-stressed and under-funded corrections facilities and saving precious law enforcement resources.”

Mr. Holder advised that we

• Broaden our approach to juvenile justice and ensure that sound research and respected analysis are a part of our decision-making process”.
• Transition from a prosecution-and-punishment model to a prevention-and-intervention paradigm.  Adopt  a comprehensive plan of action that engages law-enforcement partners, medical professionals, social services providers, lawyers, parents, teachers, coaches, mentors, and community leaders.

Mr. Holder talked about the success of the Safe Start Program, and  the launch of the Defending Childhood Initiative – the federal government’s most comprehensive effort ever to address and overcome the crisis of childhood exposure to violence, that President Obama pledged $25 million to this initiative in his budget proposal.

Mr. Holder talked about alternatives to juvenile justice involvement for youths involved in minor offenses.

• He mentioned specifically, the Civil Citations program in Miami-Dade County where youth who commit minor misdemeanors are  referred to targeted interventions aimed at reducing delinquent behavior and providing positive social outlets instead of arresting them and placing them in the juvenile justice system.  This program has reduced recidivism to 3 percent  and arrests by 30 percent for youth that participate in the program.

In addition to his emphasis on intervention and prevention over punishment, Mr. Holder also addressed the failure of our justice system to provide juveniles (as well as adults) with access to legal services.

According to The Office of Juvenile Justice and Delinquency Prevention’s Survey of Youth in Residential Placement :

• Only one half of young people in detention facilities have a lawyer.
• In many jurisdictions, youth are encouraged – whether explicitly or implicitly – to waive their right to counsel.
• When juveniles assert their right to have a lawyer, court-appointed lawyers often enter the picture too late.
• Across the country, too many public defender officers are underfunded and understaffed

Mr. Holder discussed his Department’s new Access to Justice Initiative:

• An office established in an effort to ensure that quality legal representation is available, affordable, and accessible to all Americans.
• Includes an agenda to help counties face the “impossible choice between funding critical health and human services or upholding core Constitutional rights.”

The  Office of Justice Programs is also working to implement solutions for indigent defense and juvenile justice reform by:

• Establishing the Indigent Defense Hiring Project
• Working with the National Juvenile Defender Center to establish a National Fellowship Program for law school graduates to become public defenders for three years.

March 1, 2011

The recent suicide of a student in suburban Washington, D.C., after being suspended from school has sparked a fierce debate on disciplinary policies.

Angry parents say “zero tolerance” rules are too harsh on kids. And a recent report by a Philadelphia youth advocacy group says “zero tolerance” policies are particularly harmful to minority students.

But administrators and teachers argue that strict rules are necessary to keep students safe.

In Tell Me More’s weekly parenting conversation, host Michel Martin discusses the issue with regular moms contributor Dani Tucker, Washington Post columnist Petula Dvorak and Wisconsin child psychiatrist Dr. Jenna Saul.

SCRANTON – Having just about completed the bribery and extortion portion of their case, federal prosecutors in the Mark Ciavarella trial are expected to focus on allegations the former Luzerne County judge jailed kids for cash.

U.S. vs Mark Ciavarella

• Testimony resumes today at 8:30 a.m.

• The prosecution is expected to conclude by Tuesday or Wednesday.

• Expected witnesses this week are Sandra Brulo and other current and former probation officers.

• Prosecutors are not expected to call former Judge Michael Conahan.

• Ciavarella’s defense is expected to last several days.

• The case may possibly go to jury by Friday.

The U.S. Attorneys Office presented  20 witnesses last week to establish its case that Ciavarella accepted kickbacks from the developer and extorted money out of the operator of two juvenile detention facilities, then took steps to hide the source of the income.

The government alleges Ciavarella and  former Luzerne County Judge Michael Conahan made various rulings that paved the way for construction of the juvenile centers, then worked to ensure admissions remained high so that Powell could continue paying them the kickbacks they demanded. Conahan pleaded guilty last year to one count of racketeering conspiracy.

Attorney Robert Powell, who co-owned the PA Child Care and Western PA Child Care centers, and Robert Mericle, the contractor who built the facilities, provided damaging testimony against the former jurist over four days of testimony. Powell testified for approximately 6 hours over two days, detailing how Ciavarella and Conahan repeatedly demanded money despite his protests that the facilities were not performing as well financially as the judges believed. Prosecutors say Powell paid the judges $733,500 from 2004 to 2006.

Sandra Brulo, a longtime juvenile probation department official who alleges she was threatened with termination for questioning practices within the department, will testify this week. An unknown number of current and former probation officers are also expected to testify they were pressured to detain children, even when they believed it was not in their best interest. Brulo served as deputy director of forensic programs for the juvenile probation department until February 2009, when she was charged with illegally altering a juvenile’s record. She has previously recounted a phone call she received from Conahan in which he angrily accused her of being responsible for limiting admissions to PA Child Care, located in Pittston Township. Brulo said Conahan was angry that the “ramp-up” process the state Department of Public Welfare utilized to determine the number of new admissions at the facility was too strict.

Judge Conahan began screaming at me and accused me of being responsible for the ramp-up limits. He said Robert Powell had bills to pay and that the ramping limits were limiting admissions–Sandra Brulo

Ciavarella is on trial for a 39-count indictment for charges of racketeering, honest services fraud, money laundering, bribery, extortion, wire fraud and tax evasion. Testimony resumes today at 8:30 a.m. before U.S. District Judge Edwin Kosik. The prosecution is expected to conclude its case by Tuesday or perhaps Wednesday. Ciavarella’s defense is expected to last several days, with the case possibly going to the jury by Friday. His attorneys have indicated he will testify but have not said how many other witnesses they intend to call.

SOURCE: By Terrie Morgan-Besecker tmorgan@timesleader.com
Law & Order Reporter

How can it be that young children can kill?

All states wrestle with how to protect society from children who kill while making sure they get the rehabilitation they need, and ensuring  justice for victims’ families.

The most effective rehabilitation comes from juvenile programs where young children receive therapy in a positive environment and behavioral interventions aimed at increasing empathy, self-management, and self-regulation.

In adult prison, the emphasis is on punishment. More vocational and academic programs have been added, but not every young adult prisoner takes advantage of them. Juveniles don’t do well in prison, and they certainly cannot be expected to benefit from being placed with adults with criminal thinking. Instead, in prison, they are placed in an environment where criminal thinking tends to be the social norm.

Nationally, 10 percent of all murders are committed by juveniles, according to the Office of Juvenile Justice and Delinquency Prevention. That’s about 1,043 murders a

year. More younger children are committing increasingly violent crimes. The irony is younger children have a better chance of being rehabilitated because they stay under juvenile control longer, so that therapeutic interventions and supervision continues.Most of the time violent juveniles are transferred to adult court and tried as adults. If convicted, they remain in a juvenile detention center until they are 19, and then they are transferred to the adult prison to serve the remainder of their sentence. If one happens to be tried as a juvenile and is convicted, he serves his entire sentence in a juvenile detention center and is freed by the time he turns 19.

Experts say violent crime among  juveniles is down nationally. And when it happens, we know what treatments can be effective. What works is one-on-one and group therapy and empowering a child through academic and vocational classes. What doesn’t work is Scared Straight programs and boot camps. In fact, they actually have been shown to have negative effects.

Still, for many of these kids, their time in youth facilities is not long enough to reverse a lifetime of letdowns from the adults in their lives. Nationally, 40 percent of first-time offenders return to juvenile court.

Violence toward others peaks in adolescent years, but a violent adolescent doesn’t necessarily become a violent adult. Some two-thirds to three-

quarters of violent youths grow out of it and become more self-controlled. This, coupled with the efforts to rehabilitate in the juvenile justice system, is why some

ay trying children as adults is no benefit to society.

New York State will spend  $170 million this year on 21 juvenile facilities, employing more than 2,000 employees to oversee fewer than 700 children.

The facilities are disastrously mismanaged, and as many as 80 percent of the young men who serve time end up committing more crimes within a few years of their release.

Low-risk youths — those found guilty of crimes like shoplifting, trespassing and petty theft — should be sent to community-based programs that do a much better job of rehabilitation and are only $15, 000 per youth per year, instead of $220,000 per year in the state juvenile facilities.  For youth whose families can follow through on recommendations, multisystemic therapy is a less expensive and more efficient intervention. Multisystemic therapy keeps children in their family’s homes, in their communities.

Decades of research show that keeping young offenders locked up far from their families is a sure way of turning them into career criminals. Preliminary data collected by the New York City juvenile justice system suggests that recidivism for children handled through the city’s largest community-based program, Juvenile Justice Initiative, could be lower than 20 percent. This program provides intensive counseling and services to the family, to help parents better manage the child’s behavior.

The Juvenile Justice initiative, and similar nonprofit programs have helped the city cut the number of youths it sends upstate by more than 60 percent since 2002. These programs have reduced the number of children in state facilities  from more than 2,300 in 2000 to about 680 today.

Gladys Carrión, the commissioner of the state’s Office of Children and Family Services, has closed several unneeded facilities in the last three years, with a struggle. The politically powerful unions that represent juvenile facility workers are fighting to keep facilities open no matter what the cost to children or the state.

The unions succeeded in passing a law in 2006 that requires the state to give one year’s notice to workers before closing any juvenile facility. In January the state ordered the closure of the Tryon boys’ facility in upstate Fulton County. The facility — which gained national notoriety after a mentally ill 15-year-old boy died there in 2006 — has been empty of children since June. It still has a staff of 80 people working there and will only officially shut down in January 2012.

Child Protective Services investigated more than three million cases of suspected child abuse in 2007, but a new study suggests that the investigations did little or nothing to improve the lives of those children.

In 1973, Congress passed the Child Protective Services Act, designed to encourage more thorough and accurate reporting and record-keeping in child abuse cases. In New York, for example, there are now Child Protective Services offices in every county, paid for in part with federal funds.

Researchers examined the records of 595 children nationwide, all at similar high risk for maltreatment, tracking them from ages 4 to 8, 164 that were investigated for suspected abuse or neglect, and 431 families that had not been investigated. The scientists then interviewed all the families four years later.

The scientists looked at several factors: social support, family functioning, poverty, caregiver education and depressive symptoms, and child anxiety, depression and aggressive behavior — all known to increase the risk for abuse or neglect. They were unable to find any differences in the investigated families compared with the uninvestigated in any of these dimensions, except that maternal depressive symptoms were worse in households that had been visited.

One possible interpretation of this result would be that the investigated families were at greater risk to begin with, and that the investigation helped them to recover to the expected level of risk. But if this were so, the authors write, households with recent investigations would have greater risk than households with more distant investigations. Statistical analysis found no such association. They concluded that Child Protective Services investigations had little or no effect.

The researchers were in some ways unsurprised by their findings. Even when services are offered, they usually take aim at immediate risks — substance abuse, or domestic violence — not abiding problems like poverty or poor social support. Whatever interventions were offered apparently failed to reduce the risk for future child abuse.

Dr. Kristine A. Campbell, the lead author of the study, said that it may be too easy to blame Child Protective Services. “I believe that C.P.S. has a critical role,” she said. “As a pediatrician, when I’m there in the middle of the night with a child who has been beaten up, I need them. But we have to look at other systems that can really create a safety net for these children.”

Still, C.P.S. serves an important role in gathering information. This study supports the idea that it is time for further discussion of the role of protective services, beyond investigation.The difficulty is, that C.P.S. is charged with dealing with acute issues. We do not have a means for C.P.S. to deal with the chronic, underlying issues.

The study appears in the October issue of The Archives of Pediatrics & Adolescent Medicine, has certain weaknesses: some potentially modifiable risk factors — intimate partner violence and substance abuse, for example — were not included in the data they used. And not all of the five different geographical sites systematically collected information on all risk factors.

An editorialby Dr, Abraham B. Bergman was published with the study, titled “Child Protective Services Has Outlived Its Usefulness,” and suggests some essential changes: child abuse,  is a crime and should be investigated by the police; public health nursing services should be the first to respond to concerns of child neglect; social workers should assess appropriate living situations and work with families to obtain services, and not be engaged in law enforcement.

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This article by Laura Scholes, in which she interviews Dr. Jenna, appeared first on http://www.greatschools.org

Just when the tantrums have subsided and you think it’s safe to take your child on an extended shopping trip again, don’t be surprised if you encounter another land mine in the checkout line.

“Mommy, how did the baby get into that lady’s tummy?” your five-year-old asks in a loud voice, pointing at the very pregnant woman in front of you.

As unnerving as such questions often are for parents, they’re completely normal. “In preschool, kids start noticing and asking questions about how mom and dad have different body parts,” says Jenna Saul, MD, a child and adolescent psychiatrist in Auburndale, WI. “Then, by the time they turn five, the curiosity about body parts turns into a preoccupation with where babies come from.”

At my own house, the conversation began even earlier. At two, my daughter spotted a scar on my stomach, and I fumbled my way through a TMI explanation of a C-section: my first sex talk fail.

That first (uncomfortable) sex question

Whether the first sex question happens in private or very much in public, it catches almost every parent off guard.

Katrina Alcorn, an Oakland, CA, blogger, says she never worried about the “sex talk.”

“I didn’t think it would be a big deal,” says Alcorn, who has three children. “I’m progressive. I’m body positive. I’ll make sure my kids know what they need to know.”

Then, in the car one day, Alcorn’s second grade daughter announced that she wanted to marry a girl because she didn’t want to die in childbirth.

“I was just floored,” Alcorn says. “But I tried to gather my thoughts and address her concerns one by one. I said, first of all, it’s really rare that people die in childbirth, and I don’t think that would happen to you. Second of all, it’s fine if you want to marry a girl, and you don’t have to decide now. Finally, you can adopt a baby whether you’re with a boy or a girl.”

Alcorn was proud of herself for dealing with her daughter’s questions with such aplomb — but in the end her child got the last word. “She said, ‘I still want to marry a girl because I think kissing boys is gross and anyway, I don’t want to have sex.’ I couldn’t believe the sex talk snuck up on me without me being prepared for it!”

Why you should talk sooner rather than later

Although teenagers today are waiting longer to have sex, research shows that 13 percent have had sex by age 15, and by their 19th birthday, seven in 10 teens have had intercourse. And because young adults are not marrying until their mid-20s, on average, this means they’re at increased risk for unintended pregnancy and sexually transmitted infections.

So even though talking to your young child — preschool to fifth grade — about sex may seem premature, it’s actually the ideal time to do it. As your child enters her tweens and teens and becomes self-conscious about her body and about personal matters in general, it will become increasingly difficult to raise the issue. Take advantage of this window of opportunity to create a foundation of openness and honesty with your child.

“This stuff is very hard and complicated to talk about, but for me it is a health issue,” says Robie H. Harris, a former teacher and now celebrated author of a series of children’s books about sex and the body, including It’s Perfectly Normal, and Who Has What. “I write these books because I feel that this is part of life, and it’s okay to wonder about it. It’s important not just to kids’ physical health, but also to their emotional health.”

Not one talk, but many

Most experts agree that “the talk” really isn’t a talk anymore, but an ongoing conversation, one that starts much earlier than it did even a few decades ago.

“Limiting your child’s education about sex to a single talk produces an atmosphere of shame,” says Wendla A. Schwartz, M.D., a child and adolescent psychiatrist and medical director of Solutions Psychiatric Associates in Los Gatos, CA. “Children will definitely ask, and if a parent has in his mind that a five-year-old isn’t ready for ‘the talk,’ then he gets flustered and says, ‘Go ask your mother,’ and then the mother gets flustered. Kids are great at detecting discomfort, so by the time ‘the talk’ comes around at puberty, they’ve got the idea that sex is shameful and bad, and that’s going to stick with them forever.”

Instead, make it an ongoing, low-key dialogue between you and your child that begins when they are very young and goes on throughout their tween and teenage years.

What to say, how to say it

When it comes to sex, the best strategy is to let your child lead the discussion, rather than giving her a full-blown, lengthy presentation.

“In the very early ages, parents need to focus their efforts on really listening to their children and answering their questions truthfully,” says Saul. “At first, using the child’s own language to describe body parts is a good way to make kids comfortable; then you can teach them the actual names — penis, vagina, womb — as it becomes appropriate.”

Schwartz agrees that parents should let kids take the lead. “The best approach with all kids is to only answer the question they ask,” she says. “One of the really beautiful things about young children is that they’re incredibly inquisitive. They have such a tremendous level of curiosity that you really don’t have to worry that they’re going to forget to ask. As they’re ready for the information, they will probe for it.”

So when the questions start coming, give as brief and as honest an answer as you can and know that when they’ve learned enough, they’ll tune out — and that’s fine. Be prepared by having some age-appropriate books on hand before your child starts asking questions. Robie Harris recommends reading through the books by yourself first, to make sure you agree with the information and the way it’s presented. Books can help neutralize a charged topic; they also give your child the opportunity to do additional research on her own.

Kids are resilient

Don’t worry if you flub the sex conversation the first time — or even the second.

“We all make mistakes,” says Schwartz, who has stumbled on the topic of sex with her own kids. “Don’t freak out if you don’t get things right. Remember: over the years you’ll get plenty of chances to ‘practice’ giving good information. Besides, lucky for us, kids are amazingly resilient.”

To see the article where it originally appeared, go to:

http://www.greatschools.org/parenting/sex-education/5288-how-talk-younger-child-sex.gs?page=all

Researchers at the University of California, San Diego, have identified a rare, hereditary form of autism that may be treatable with nutritional supplements,

For three days next week,, Yale Law School will pilot a program allowing its students to check out a “therapy dog” for up to 30 minutes at a time. A memo written by the law librarian, Blair Kaufman, to students noted that therapy dog visits have resulted in  “increased happiness, calmness and overall emotional well-being”.  The program is requesting the students’ feedback to determine whether this program should be a permanent and ongoing program.

A caring operation that’s run for donkeys’ years

DONKEYS have a special place in our history, carrying wounded soldiers in World War I and bearing miners’ tools underground in the gold rush.

But for all that laboring, the humble donkey has had little respect and undertstanding. Australian psychiatrist May Dodd may be the donkey’s best human friend.

Dr. Dodd  runs Victoria’s only donkey hospital and refuge, at her Diamond Creek property and in Tongala. In the days following the Black Saturday bushfires, Dr Dodd evacuated 91 donkeys, on cattle trucks, to safe ground near Echuca. She drove her donkey ambulance through police roadblocks into places such as Kinglake, Chum Creek and Dixons Creek, while the ground was still smouldering.The psychiatrist has cared for more than 300 donkeys in the past 13 years at her home on Ironbark Road, where she also runs her private medical practice full time. The last fire-affected donkey, Moomba, went back home to Humevale just a few months ago, still partially blind from burnt eyes.

Dr Dodd says donkeys and psychiatry may seem an odd match, but they complement each other.

”One is all about the mind and the other is mostly physical work, so it’s a great balance,” she says. ”I have this propensity to protect minority or marginalized groups. Mentally ill patients are often shunned and donkeys are also forgotten by society. But donkeys also have a calm tranquility about them which I, and my patients, enjoy.”

”Donkeys are more dog-like than horse-like; they are inquisitive, affectionate and like to follow you around for a pat.”

Her father was a horse jockey from age 10 in Newmarket, the headquarters of British racing, but Dr. Dodd was always terrified on a horse, preferring the donkey’s slower gait.

But no matter how often he put his only child on a horse, she was always terrified. Instead, she preferred a donkey’s slow plod.

Dr Dodd broke with the family horsing tradition when she completed her medical degree at the University of London.

Not long afterwards, in 1981, she responded to an advertisement calling for doctors to come to Australia. She was meant to work for just two months at the Plenty Valley Repatriation Psychiatric Hospital, but never left.

Dr Dodd sees about 26 patients a week in Diamond Creek, where she lives alone, and cares for the donkeys in her spare time. ”Initially I took a few donkeys on because I had the space” but she had a  difficult time turning any away.

She lends donkeys for work with troubled children and events like Remembrance Day.

The above is excerpted from:

A caring operation that’s run for donkeys’ years

Marika Dobbin

January 5, 2011

There are a number of  current integrative and complementary treatment studies for children and adolescents.

Timothy Culbert is the medical director of the integrative medicine program at Minneapolis-based Children’s Hospitals and Clinics of Minnesota, one of the largest hospital-based, pediatric complementary medicine programs in the country.  Dr. Culbert and his colleagues are about to launch a study at four hospitals in the U.S. and Canada to examine in greater depth the use of nondrug coping skills in kids with cancer.

Several years ago, they developed a “Comfort Kit” designed to teach children coping skills including: deep-breathing relaxation techniques; aromatherapy, in which patients inhale chemicals produced by plant oils; and acupressure, a variant of acupuncture with pressure applied to certain points in the body. 

In several pilot studies, Dr. Culbert’s team found that kids can learn such skills and appear to find them helpful. In one study of 150 kids who underwent surgery , 87% said the techniques helped them cope with pain after the procedure. Another study found that a majority of kids with cancer felt relief from their nausea with accupressure. 

 At the University of Alberta in Edmonton, Canada, Sunita Vohra is running a clinical trial with 80 participants to examine whether a self-calming strategy can help children with a variety of diagnoses, including attention-deficit hyperactivity disorder and opposition-defiant disorder. The aim is to teach children to focus on “their presence in the moment”—by paying attention to breathing and other sensations and blocking out external commotion.

Vohra is beginning an individualized study of the use of probiotics—micro-organisms thought to be healthy for the person that consumes them—with gastrointestinal diseases. Dr. Vohra is also studying whether melatonin aids sleep in kids with attention-deficit hyperactivity disorder. 

Wake Forest’s Dr. Kemper has investigated the pediatric use of music therapy, chiropractic care that involves manipulating the body, and “healing touch,” which is based on the premise that the presence of one person’s electromagnetic energy field has an affect on another person. 

Dr. Kemper’s research, including one published in the journal Pediatric Research, has shown that music helps soothe kids with cancer. In 2008, she and her colleagues published findings on eight premature infants showing that live harp music can help them gain weight. Previous findings depicting this effect puzzled them, because such babies can’t increase the number of calories they are eating on their own.

To figure out what was going on, Dr. Kemper’s group put devices called actimeters, which measure very small movements, on the legs of the infants and found that those babies who were exposed to the music were alert and paying attention compared to those in a quiet room or getting the usual care. Soothed babies exhibit fewer tiny muscle movements compared with more tense babies, which reduces the amount of calories they burn.

 It isn’t always clear from these studies what the active ingredient is that’s responsible for the apparent benefit of the therapy. Recent preliminary findings from Dr. Kemper’s group show that kids with cancer report feeling calmer, less anxious and more comfortable in the presence of someone performing healing touch. Yet the study can’t tease apart whether it is the mere presence of a calm person in the room or the actual healing touch that appears to affect the patient.

A method that is safe can be utilized even if it is not shown to be effective, because it gives children and families a sense that they are doing something. The caution is that if a therapy has side effects,expensive, or is used in place of a therapy known to be effective, then the risks outweight the benefits.

“OSR#1 is not a dietary supplement but a toxic, unapproved drug with serious potential side effects”  the FDA warns, says the June 23 Chicago Tribune article.

OSR#1 is an industrial chelator that  is now being marketed as a supplement to treat autism.

According to CTI Science’s website, “OSR#1® is a toxicity free, lipid soluble antioxidant dietary supplement that helps maintain a healthy glutathione level”.

The FDA wrote a letter of warning to Boyd Haley, the president of CTI Science indicating that they are making unapproved claims:

Your firm markets OSR#l as a dietary supplement; however, this product does not meet the definition of a dietary supplement in section 201(ff) of theFederal Food, Drug, and Cosmetic Act,

“The claims listed above make clear that OSR#1 is intended to affect the structure or any function of the body of man or other animals. Accordingly, OSR#l is a drug under section 201(g)(1) of the Act, 21 U.S.C. § 321(g)(1). Disclaimers on your website, such as “OSR#l® is not a drug and no claim is made by CTI Science that OSR#1® can diagnose, treat or cure any illness or disease,” do not alter the fact that the above claims cause your product to be a drug.”

They go on to indicate that this new drug may not be introduced or delivered for ….interstate commerce…because there is no FDA-approved application in effect for the product.

“Additionally, under section 502(a) of the Act, 21 U.S.C. § 352(a), a drug is misbranded if its labeling is false or misleading in any particular”…”Your website states that” [s]ome reports of temporary diarrhea, constipation, minor headaches have been reported but these are rare and the actual causes are unknown,” as well as “OSR#1 is without detectable toxicity” and “OSR#1® … has not exhibited any detectable toxic effects even at exceptionally high exposure levels.” However, animal studies that you conducted found various side effects to be associated with OSR#1 use, including, but not limited to, soiling of the anogenital area, alopecia on the lower trunk, back and legs, a dark substance on lower trunk and anogenital area, abnormalities of the pancreas, and lymphoid hyperplasia. Based on these animal studies and side effects known to be associated with chelating products that have a similar mechanism of action to OSR#1, we believe the use of your product has the potential to cause side effects, and the before-mentioned website statements falsely assert that the product does not have the potential to cause side effects. Therefore, these statements render your product’s labeling false or misleading. ”

In response to prior Chicago Tribune articles, Boyd Haley was on Twitter stating ”

“Contrary to the Chicago Tribune implication, OSR1 has undergone extensive safety testing. The truth is at www.OSR1.com. Please retweet!”

However, on the OSR1.com website, there is no mention of these test results.  There is a “safety and pharmacokinetics summary“, but it doesn’t discuss or cite the “extensive studies” .

The Tribune quotes Ellen Silbergeld, a John’s Hopkins researcher:

“It would be hard to imagine anything worse,” said Ellen Silbergeld, an expert in environmental healthwho is studying mercury and autism at Johns Hopkins University’s Bloomberg School of Public Health. “An industrial chemical known to be toxic — his own incomplete testing indicates it is toxic. It has no record of any therapeutic aspect of it, and it is being marketed for use in children.”

Kim Stagliano, Managing Editor of the “Age of Autism” blog has written in an email that was quoted in the Tribune Article : “I continue to trust his science,” . “I’m sure CTI Science will address the letter appropriately.” This physician-scientist is confused.  Boyd Haley has not provided science to support that this agent is effective and safe to the FDA, and I cannot find any citations on his website to scientific research.  Prof. Haley appears to have withheld safety information from the autism community. It is his own “science” that suggests this chemical is toxic.

A new device, called the Quotient, uses a motion tracker to try to help determine whether a child has Attention Deficit Hyperactivity Disorder.  The device was invented by  Dr. Martin Teicher,  Harvard Medical School associate professor.The designers feel that this is a more objective test to use for the diagnosis of ADHD than anything else that currently exists, and this is important because the lack of a reliable test to help parents and clinicians be certain of the diagnosis of ADHD has made it difficult for parents to feel comfortable about deciding to use medications in the treatment of their children.

BioBehavioral Diagnostics, of Westford and Philadelphia, says its device can distinguish between the restlessness and jitters of a child with ADHD and the movements of one who does not have the disorder, to help parents and clinicians feel more confident about the diagnosis.

Some skeptics believe that the Quotient is very similar to the continuous performance test, (CPT), where a patient works at a computer to complete tasks while the computer records the number and types of errors the patient makes. Use of the CPT has diminished greatly, due to concerns that the results do not closely correlate to a diagnosis of ADHD.  The developer of the Quotient feels that the camera greatly improves the accuracy of the test, compared to the older CPT.  The patient will play a simple game while sitting at the computer, and is asked to touch the space bar when stars flash on the screen. Impulsivity and concentration are measured by the task, while the infrared cameras in the kiosk record the movements of the patient. The developers say that while persons with and without ADHD complete the attention task, their movements are very different. A person with ADHD moves more, but also moves more simply, while a person without ADHD moves more erratically.

In a study published in the Journal of the American Academy of Child and Adolescent Psychiatry in 1996, Teicher reported that the device accurately identified 16 of the 18 children who had been previously diagnosed with ADHD, and all 11 controls without ADHD.

In 2004, BioBehavioral Diagnostics approached McLean to develop Teicher’s work into a marketable diagnostic tool

The test has been approved by the Food and Drug Administration, and currently 60 Quotient kiosks are in use across the country.The device costs clinicians $19,500; the company then charges $50 per child and $55 for adults for providing a computer-generated report for each patient.

Researchers at UC San Diego and UC Davis examined chocolate consumption and other dietary intake patterns:

• 931 males and female participants who were not using antidepressants
• participants were also given a depression screening test

Results:

• Those that screened positive for possible depression consumed an average of 8.4 servings of chocolate per month
• People that were not depressed consumed 5.4 servings per month
• The highest scorers on the mood tests, indicating possible major depression, consumed 11.8 servings per month
• Findings were similar among women and men
• After controlling for other dietary factors that could be linked to mood — such as caffeine, fat and carbohydrate intake, only chocolate consumption correlated with mood.

A serving of chocolate was defined as one ounce of chocolate candy

The relationship between chocolate and depression exists, but how the two are linked is unclear.

It could be that depression stimulates chocolate cravings as a form of self-treatment.

• Chocolate prompts the release of certain chemicals in the brain, such as dopamine, that produce feelings of pleasure.
• There is no evidence, however, that chocolate has a sustained benefit on improving mood.
• Like alcohol, chocolate may contribute a short-term boost in mood followed by a return to depression or a worsened mood.
• A study published in 2007 in the journal Appetite found that eating chocolate improved mood but only for about three minutes.

It’s also possible that depressed people seek chocolate to improve mood but that the trans fats in some chocolate counteract the effect of omega-3 fatty acids–thought to improve mood–in the body.

Another theory is that chocolate consumption contributes to depression or that some physiological mechanism, such as stress, drives both depression and chocolate cravings. It is possible that eating chocolate for comfort is a learned behavior; Chocolate is popular in North America and Britain, but in other cultures, different foods are considered pleasure-inducing pick-me-ups.

In the February 2010 volume of Archives of General Psychiatry, researchers G. Paul Amminger, Miriam R Schafer et al published the findings from their randomized, placebo-controlled trial, conducted between 2004 and 2007. They identified 81 individuals at very high risk of developing a psychotic disorder, and provided 12 weeks of 1.2 grams daily of omega three polyunsaturated fatty acidsin the treatment group, and placebo n the control group. They monitored the patients afterward for 40 weeks.

The ration of omega 6 to omega 3 fatty acids in red blood cells was used to determine pre- and post-treatment fatty acid composition.

76 participants completed the study, and at the end, 2 of 41 (4.9 %)individuals in the omega three treated group, compared to 11 of 40 individuals (27.5%)in the placebo group had developed a psychotic disorder. This was determined to be a significant difference. Treatment with omega three polyunsaturated fatty acids also reduced positive symptoms, and negative symptoms, as well as general symptoms. Functioning was also determined to be improved.

There was no difference in adverse effects of the treatment versus placebo.

The treatment team concluded that long-chain omega three polyunsaturated fatty acids reduce the risk of progression to psychosis, and may be a more safe and effective strategy for prevention that antipsychotic medications, for youth with subthreshold psychotic states.

A randomized controlled trial of acupuncture for depression during pregnancy suggested that symptoms were reduced with a response rate similar to standard depression treatments.  Acupuncture may be a viable treatment option for depression during pregnancy.

150 pregnant women who met criteria for major depression were given either acupuncture specific for depression or one of two active controls: control acupuncture or massage. They received 12 sessions during 8 weeks. The acupuncturists who administered treatment were blinded to treatment assignment. The Hamilton Rating Scale for Depression was used to rate severity. 63% of the women who received depression-specific acupuncture reported a significant reduction in symptoms, compared to 44% of women in the other two groups combined.

Many pregnant women with depression stop taking medications when they become pregnant, due to concerns this may harm their unborn babies.  Women with depression are at increased risk for preterm births, and are at increased risk for post partum depression, so treatment of depression during pregnancy is important. Post partum depression interferes with a woman’s ability to care for her infant, and can have lasting effects; previous studies suggest that children of mothers with postpartum depression perform more poorly in school, become frustrated more easily, and have poorer problem solving.

Acupuncture may be a good option in treating depression in pregnant women; this treatment appears to be more effective than other tested non-pharmacologic treatments. Depression during pregnancy is common; up to 14% of women may have depression when pregnant.

Acupuncture for depression during pregnancy: a randomized controlled trial.

Manber R, Schnyer RN, Lyell D, Chambers AS, Caughey AB, Druzin M, Carlyle E, Celio C, Gress JL, Huang MI, Kalista T, Martin-Okada R, Allen JJ.

Obstet Gynecol. 2010 Mar;115(3):511-20.PMID: 20177281

According to a soon-to-be-published study in the Journal of Affective Disorders, Swedish researchers concluded that only a small proportion of depressed adolescents with hypomanic episodes will develop bipolar disorder in adulthood.

The study participants came from a community-based sample of 2300 adolescents who were screened for depression and hypomania between 1991 and 1993.

• Of these, 64 individuals aged 16-17 years who screened positive for symptoms  of depression and lifetime hypomania spectrum symptoms participated in follow up interviews after an average of 14 years.
• Only six of the 64 individuals experienced another hypomanic episode, or an episode or mania, by the age of 30-33 years.

Author Paaren Aivar, with Uppsala University, and his co authors, thus concluded that

“maintenance or prophylactic treatment does not seem warranted for [youth who have experienced a hypomanic episode].”

Of the group of 2300 adolescents who screened  positive for depressive symptoms, 90 also screened positive for full syndromal hypomania lasting more than 4 days (n=40 [1.7%]), brief-episode hypomania lasting less than 4 days (n=18 [0.8%]), or subsyndromal hypomania (n=32 [1.4%]), and 64 of the 90 adolescents participated in follow-up interviews after an average of 14 years.

• Only  four (6%) of the participants interviewed at follow-up reported at least one episode of hypomania in adulthood
• Only  two (3%) reported at least one episode of mania.
• 38 (59%) met criteria for major depression at follow-up.

Aivar et al  further conclude:

“…a significant number of adolescents initially diagnosed with full-syndrome, brief-episode, and subsyndromal hypomania did not develop bipolar disorder as adults. However, a substantial proportion reported major depression later in life.”

This is consistent with previous findings that suggest that youth with mood symptoms in childhood and adolescent continue to be most at risk for developing major depression, and not bipolar disorder, as adults.

The researchers echo what many clinicians have attempted to explain to frustrated and confused parents for many  years; that we continue to have very little ability to recognize youths at risk of developing bipolar disorder.

Dr. Aivar et al  conclude  that long-term prophylactic pharmacological treatment in children with hypomania spectrum disorder   is not warranted.

The risks of psychopharmacologic treatment to prevent the development of bipolar disorder outweigh the potential benefits for youth, even if they have been diagnosed with full-syndrome of hypomania.

J Affect Disord 2012; Advance online publication

Most children with rapidly shifting moods and high energy have other mental disorders, not bipolar disorder, according to a NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010.

Background

Though some researchers feel that mania in children is exhibited when a child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. But rapid mood swings and high energy are actually common in youth.

Overdiagnosis and misdiagnosis of bipolar disorder in youth seems to explain the increased numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder.

The Longitudinal Assessment of Manic Symptoms (LAMS) Study

• 707 children, ages 6-12, referred for mental health treatment.
• 621 participants were rated as having rapid swings between emotions and high energy levels, described as “elevated symptoms of mania” (ESM-positive).
• Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative.

Study Results

• At baseline, all but 14 participants had at least one mental disorder, and many had two or more.
• Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study.
• Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system.
• Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes.

Children with rapid mood swings and high energy:

• Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD
• Had lower functioning at home, school, or with peers
• Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder).

Important Points:

• 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder.
• Thus, Bipolar disorder may not be common among children who experience rapid shifts in emotions and high energy levels.
• Children with rapid mood swings and high energy levels experience significant impairments due to mood and behavior problems.
• The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children.

Study Follow up:

The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. This research may help identify predictors of the illness.

Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.

Young men who attempt suicide before age 18 are much more likely as adults to be aggressive toward their girlfriends or wives, including hitting and injuring their partners.

The Study, published online in Psychological Medicine is based on data from 153 males from higher-crime neighborhoods who were assessed yearly from ages 10 to 32, and their romantic partners who participated when the men were ages 18 to 25.

This  new research highlights the need for intervention with suicidal teens: 58 percent of youth in that study group who attempted suicide went on to injure a partner, compared to 23 percent of young men who did not attempt suicide.

The study began when the men were kids, and before anyone had data to predict who would become violent. David Kerr of Oregon State University and Deborah Capaldi of the Eugene-based Oregon Social Learning Center, controlled for other problems suicidal youth can have which are also linked to violence to partner, such as aggression, depression, substance use, and family abuse history.

The researchers still found that young men who attempted suicide were more aggressive toward their partners.

The researchers had data from official domestic violence arrest records, women’s own reports of injury, and live observations of the couples.

In the past, domestic violence has been primarily attributed to cold, controlling and calculating individuals.

This study supports a growing body of research indicating that both men and women who are physically aggressive toward a partner have histories of aggressive and impulsive  behavior.

This study is important for prevention and treatment as well:

If a man is told that domestic violence is due to a need to coldness, a need to control, and systematic battering,  he may dismiss his difficulties, since this pattern doesn’t apply to him. If clinicians explain to men that their difficulties are related to the need to control anger and impulsive  reactions while under stress, they may be more aware that they are at risk, and better able to take responsibility for treatment.

Scientists  have used fMRI to help determine whether children have severe irritability and ADHD or a form of bipolar disorder. This technique appears to separate youth with bipolar disorder from those with chronic irritability.

Very irritable children with ADHD share some characteristics with children with bipolar disorder, but also have significant differences

• very irritable children with ADHD don’t have the distinct episodes of mania that one sees in classic bipolar disorder, and they don’t tend to have as much bipolar disorder in their family history
• very irritable children with ADHD and those with bipolar disorder
• both get frustrated more easily than children without these diagnoses
• shared deficits in social cognition: both have difficulty reading facial emotional cues

Data like these suggest that eventually psychiatric diagnosis will be based on brain mechanisms in addition to symptoms

Using MEG technology, some of the brain regions responsible for the difficulty that children with bipolar disorder have regulating their emotions when frustrated have been identified.

• the anterior cingulate, a region that directs attention to important signals in the environment, functions differently in children with bipolar disorder, compared with healthy children, when they are in frustrating situations.
• the anterior cingulate acts in concert with the prefrontal cortex, an area that organizes behavior — and here too the researchers found differences between the responses of patients and healthy children.

A similar study in children with severe irritability and ADHD is being conducted, to see once again if the brain mechanisms involved in frustration differ between this group and children with bipolar disorder.

CLAUDIA M. GOLD
Warning label on new diagnosis
By Claudia M. Gold  |  March 1, 2010, The Globe
 
I SAW 5-year-old Alex with his parents in my pediatric practice (details have been changed to protect privacy) for “explosive behavior and irritability.’’
 
One morning Alex’s father, Ben, called to Alex upstairs and asked if his younger sister could have some of his pancakes. There was a misunderstanding; Ben thought he said “yes’’ but Alex insisted he had said “maybe.’’ Alex came into the kitchen and found his sister eating his pancakes. He immediately began to scream, and threw her plate on the floor.
 
He hit his mother, Carla, who, overwhelmed with rage herself, grabbed him and carried him up the stairs to his room. There he attempted to kick the door down. After about 45 minutes, both Alex and Carla collapsed in tears of exhaustion and frustration. This type of scene occurred in their home several times a day.
 
I met with Ben and Carla alone, and they described Alex as a challenging baby from the start. Carla cried as she spoke of her own abusive father and her difficulty managing her anger. She decided to address these issues in her own therapy. Ben told of stresses in their marriage that they felt had resulted from having such a difficult child. Over time, as these issues were brought to light, Ben and Carla felt better equipped to help Alex contain and manage his frustration. Though the problems are far from resolved, a more positive pattern of interaction was set in place, and Alex’s development is on a healthier track.
 
I thought of this family while reading about the controversy swirling around the proposed new diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: temper dysregulation disorder with dysphoria (negative, unhappy mood). An 11-page justification for the addition of the new diagnosis, written by the Child and Adolescent Disorders Work Group, begins with reference to a 40-fold increase in the diagnosis of pediatric bipolar disorder since the mid-1990s. That statistic is, in my opinion, justification enough.
 
A new diagnosis could be a first step off of the path child psychiatry is now on. Use of antipsychotics, powerful drugs with serious side effects, for 2- to 5-year-olds has doubled in the past several years. While medication can be an important part of treatment for older children, a different way to think about “explosive’’ behavior that does not necessarily involve medication is urgently needed.
 
Problems with the new diagnosis abound. There is no guarantee that clinicians will be any less likely to prescribe antipsychotics for this disorder than for bipolar disorder. Though the intention is to view this disorder as biologically based, the authors of the justification report acknowledge that evidence for the biological basis of any psychiatric disorder is “very preliminary.’’ Insurance companies may not cover treatments other than medication.
 
Allen Frances, chair of the DSM-IV Task Force and a harsh critic of DSM-V, refers to the diagnosis as “a misguided medicalization of temper outbursts.’’
 
He worries that the diagnosis would be very common in the general population and promote a large expansion in the use of antipsychotic medication. I agree that this is a risk. Aggression and temper tantrums are a healthy normal part of development. It would be wrong to label children exhibiting these behaviors with a disorder.
 
But families like Alex’s are suffering. It is important to find a way within the DSM system to describe their experience without use of the bipolar label. The criteria for the diagnosis must clearly reflect the intensity, frequency, and disruptive nature of the problem.
 
I hope that this new diagnosis will open up discussion about the meaning of these children’s behavior. Use of the word “dysregulation’’ is an important first step. Extensive research at the interface of developmental psychology and neuroscience has demonstrated that young children learn to regulate emotions in the setting of relationships with their caregivers.
 
A child may be born with a genetic vulnerability for emotional dysregulation. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.
 
Emotional “dysregulation’’ is an accurate description of Alex’s behavior. DSM-V is primarily a descriptive document that does not address cause. However, if clinicians treating this new disorder think about emotional regulation as a quality that is learned in relationships, it may open up a path to considering meaningful alternative interventions.
 
Dr. Claudia M. Gold is a pediatrician in Great Barrington.

Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria

Written by Nestor Lopez-Duran PhD on Wednesday, February 10.2010 from childpsych.org

Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes,  there are a few areas where the DSM-V will likely make some drastic changes.  Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).

Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar.  Instead, 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:

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.

References:

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