Preschool Meds
Sheryl Gay Stolberg, New York Times Magazine- 11/17/2002

On a warm, breezy Friday in September, a parade of mothers in minivans arrived at a preschool in suburban Connecticut to drop off a collection of 4-year-olds. Among the young students was Sam G., a sturdy, big-eared boy with cheeks that flush easily and a personality that has earned him a reputation, politely speaking, as a handful. Like most 4-year-old boys, Sam loves things that move -- trains, planes and trucks, especially fire trucks -- and is usually on the move himself. When he enters a room, his clear blue eyes dart about, as though he cannot take in the sights fast enough. His knees and elbows are perpetually scraped. When his teachers read stories aloud, Sam often wanders about.
   This particular Friday was no exception. It was Bring-Your-Stuffed-Animal-to-School Day, and Sam burst through the door carrying a two-foot-tall black-and-white cow he calls Moo. Surveying the scene, he paused momentarily and then, as if someone had lighted a fuse underneath him, thrust his arms forward and began zipping around the room, the cow acting as his shield. During the next two hours, Sam tried to open the childproof window locks; he got into fights in the sandbox and repeatedly stood in the center of the room, swinging the cow by its tail. When his teacher finally put the animal on the shelf "for a nap," Sam burst into tears.
   Time was, Sam's rambunctiousness would have been chalked up to childhood or, more precisely, boyhood. Today, Sam has a diagnosis -- attention deficit hyperactivity disorder, and a potential treatment: methylphenidate, a drug better known by its brand name, Ritalin. Sam has been taking the drug, in various doses that are interspersed with dummy pills, since July as part of the three-year Preschool ADHD Treatment Study, known as PATS. This unusual clinical trial is financed by the National Institute of Mental Health and overseen by the New York State Psychiatric Institute in Manhattan. The institute, which is affiliated with Columbia Presbyterian Medical Center, is one of six academic medical centers around the country that have been recruiting children since January 2001. The aim is to enroll 314 children by February. Results are expected sometime in 2004.
   The research may be the most controversial medical experiment the federal government has ever conducted in children: a study of the safety and effectiveness of generic Ritalin in pre-schoolers, ages 3 to 5. Experimenting on children is always delicate, especially when the children are barely out of diapers. Ritalin, marketed to help hyperactive students focus in school, is a stimulant, and though it is generally considered safe, scientists acknowledge they do not understand how it affects young children's developing brains. The drug is not approved for children under age 6. But doctors increasingly prescribe it to them "off label" -- a worrisome trend, yet hardly surprising in an era when 3-year-olds are expected to know their numbers and 5-year-olds are being taught to read.
   "We have an obsession with performance in our country," says Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif, and the author of two books on A.D.H.D. "We have a universal performance enhancer in Ritalin. It helps anyone, child or adult, A.D.H.D. or not, to perform better. It was inevitable that there would be this drift down to the 3- to 5-year-old set."
   Darlene and Brian G., who insisted that their last names not be used to protect Sam's privacy, had struggled for years to have a child. Darlene, a compact 51-year-old woman with blond hair and jade-green eyes, was 39 when she married Brian, an engineer 13 years younger than she is. In 1997, having exhausted their emotional and financial resources on in vitro fertilization, they decided to adopt. Sam was born Dec. 18 of that year to a 17-year-old. Only later would the couple learn that their son's biological mother, as well as some of her relatives, had been given the diagnosis of attention deficit hyperactivity disorder.
   By the time Sam started walking, two things about him were clear: he was fearless and always on the go. When he was 2, Sam climbed onto the dining-room table and tried to swing from the ceiling fan. He switched on the electric stove, then stretched his little body across the burners. He tripped the latch on a sliding-glass door, then let himself out on the second-story balcony. Darlene yanked him back as he was about to topple over the rail.
Brian thought Sam was just being a boy, and the pediatrician seemed to concur. When Darlene asked about testing for hyperactivity, he told her to wait until Sam was 5 or 6, and in school. "If I live that long," she shot back. When Sam was 3, the director of his preschool called to say that Sam had raised his fists to her "and we can't have that kind of behavior here." Darlene, upset yet relieved that someone else had seen what she saw, called Brian in tears. "He's going to get kicked out of preschool," she told him. "He's only 3!"
   A local psychologist diagnosed A.D.H.D. in Sam and recommended therapy. Darlene, a believer in holistic medicine, also took Sam to a naturopath, who tested him for food sensitivities and severely restricted his diet: no wheat, dairy, gluten, corn syrup or food additives. The entire family gave up pizza. At school birthday parties, Sam got soy ice cream.
   By the time Sam turned 4, the family's insurance coverage for the therapy was running out. Then Darlene's cousin alerted her to an advertisement in The New York Daily News. "Is your preschooler just too active?" the ad asked. It promised "a comprehensive evaluation by our study team, as well as up to 14 months of treatment --all at no cost."
   The man behind the advertisement was Laurence L. Greenhill, a 61-year-old child psychiatrist at the Psychiatric Institute on Riverside Drive in New York City. Square-shouldered and stocky, with wire-rimmed glasses and dark wavy hair that he slicks down for speaking engagements, Greenhill is what pharmaceutical companies call a K.O.L. -- key opinion leader -- which means he conducts the cutting-edge drug research that shapes prescribing decisions for thousands of ordinary doctors who treat A.D.H.D. He is serious almost to the point of being humorless, a trait that colleagues say serves him well. "Among people who do work like this, studies on the very young, the very sick, there is no shortage of cowboys," says Steven Hyman, who was the director of the National Institute of Mental Health at the N.I.H., when the study was approved. "Larry Greenhill is not a cowboy."
   Greenhill came of age in psychiatry at a time when medical experts were beginning to regard hyperactivity as not simply a behavioral disorder but a condition with a biological basis, akin to asthma or diabetes, that could be corrected with medicine. In 1998, having already helped lead a landmark study of Ritalin in school-age children, he turned his attention to preschoolers. In November 1999, the National Institute of Mental Health agreed to finance his preschool study. But before the money was released, a scientific landmine exploded in the middle of the long-running Ritalin debate. In February 2000, The Journal of the American Medical Association reported a twofold-to-threefold increase in the use of stimulant drugs, particularly methylphenidate, among 2- to 4-year-olds. The study, by Julie Magno Zito, a pharmacy professor at the University of Maryland, did not shock doctors who treat A.D.H.D. But it did shock the public. "Those of us who have been prescribing medication since the 70's had been watching this huge increase," Lawrence Diller says. "Zito's piece put it on the front page of every newspaper."
   Hillary Clinton, still first lady but running for Senate in New York, demanded to know what the government was doing about it. Hyman told her about Greenhill. Within weeks, the White House had announced a major initiative to reduce the use of stimulants among the very young. The preschool study was a central component.
   Critics argue that the trial may, in fact, increase stimulant use, legitimizing it for children who are not as closely monitored as Sam. But Hyman defends his decision to go ahead, given that so many preschoolers are already on the drug. "If we can do these trials right," he says, "we are damnable if we don't do them. Because if we don't do them, then every child becomes an uncontrolled experiment of one."
   To Peter Breggin, the nation's best-known A.D.H.D. critic, the study marked "a tragedy for America's children." A soft-spoken, silver-haired psychiatrist, Breggin is the author of more than a dozen books, including "Talking Back to Ritalin." With his gentle manner and frequent television appearances, Breggin puts forth an appealing -- and, Greenhill contends, troubling -- message: attention deficit hyperactivity disorder is a figment of modern psychiatry's imagination.
   Flipping through the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders on a recent afternoon, Breggin read aloud from its list of A.D.H.D. symptoms: "Often fails to give close attention to details or makes careless mistakes in schoolwork. Often fidgets with hands or feet or squirms in seat. Often blurts out answers before questions have been completed." He scowled. "There is no disease," he said flatly. "It's a list of behaviors that annoy adults."
   On January 23, 2002, Sam and his parents made the first of what would become weekly visits to the psychiatric institute. They had come to meet Dr. Janet Fairbanks, the child psychiatrist and colleague of Greenhill's who would evaluate Sam. Diagnosing A.D.H.D. is difficult with any child, but with preschoolers, who tend to be active and impulsive, it is especially hard. The medical literature suggests A.D.H.D. is often overdiagnosed and overtreated, which is one reason Breggin's arguments have gained so much currency.
   Contrary to the perception that Ritalin is being used as a kind of "chemical handcuff " for inner-city kids, studies show the drug is most often prescribed to white suburban boys -- in short, kids like Sam. Sensitive to the controversy, the mental-health institute insisted that Greenhill's team require parenting training: 10 weeks of classroom instruction in behavior modification. Children who show little or no improvement at the end of the 10 weeks then become eligible for medication.
   The team also set strict limits on who can enroll, taking only the most severely affected children. Fairbanks knew right away Sam would qualify. The electric stove story, she says, was a big tip-off. "He has no sense of danger, which is characteristic of these kids, which is why they get hurt a lot. It's curiosity, combined with no impulse control."
   By April, the psychiatric institute had recruited enough children, 13 in all, including a set of 3-year-old twins, to begin its next round of parent training. The course was led by Tova Ferro, a clinical psychologist who herself was expecting a child. On the night I sat in, the lesson was timeouts. Ferro popped a video into a recorder, and a man appeared on the television screen, begging his toddler to put away her toys amid lame threats of a timeout. Ferro asked what the father had done wrong. "He was a wimp," one mother piped up. Ferro agreed. She advised the parents to make a list of behaviors serious enough to warrant a timeout. Every family is different, she told them. "Think about what makes sense for you." Although her goal is to help parents improve their children's behavior, Ferro is under no illusions. "Some children will need additional interventions," she said. Translation: Some will need drugs.
   For Brian and Darlene, the parent training was mostly a review of what they had already picked up in parenting books, though they enjoyed the emotional support. But as with every other aspect of the PATS clinical trial, the parent training, modeled on a Canadian program, has critics. Among them is William E. Pelham Jr., director of the Center for Children and Families at the State University of New York at Buffalo. At his center, Pelham offers intensive training for teachers and summer camp for hyperactive kids -- programs that he says help as many as 75 percent avoid medication. He says that Greenhill's less intensive training is set up to fail. "I bet you 100,000 bucks I could tell you the results of that trial," Pelham said. "The results will be that kids need medication because parent training is not enough. I think that's dangerous. It is going to send a message to people that young children need medication." But the cold truth, says Hyman, the former director of the mental-health institute, is that few Americans could afford the kind of help Pelham offers. "We were very concerned," he said, "that any behavioral therapy that came out of this trial had to be generalizable."
   In Sam's case, the training was of little help, and the question of whether to put him on medication was much on his parents' minds throughout the 10-week session. On Sam's good days, Darlene was convinced she should hold out until he started school. On bad days, she was ready to cave. In the end, it was Brian who made the decision. He liked the idea that Sam would be carefully monitored, that his medication would be increased only gradually until doctors determined the optimal dose, which he would take for 10 months. The father who once insisted his son was just being a boy had come to accept him as a boy with a problem. "My eyes," Brian said, "have been opened."
   Sam started the medicine on the first Saturday in July. The following Friday, he strutted into the institute wearing one of his many fire truck shirts. His mother was glowing. "Today," Darlene announced, "was wonderful." In keeping with the study requirements, Fairbanks started Sam on an extremely low dose, 1.25 milligrams of methylphenidate, once a day. Every two days, the dose went up; by Thursday, Sam was on 7.5 milligrams once a day, still much less than the study's maximum dose of 7.5 milligrams three times a day. Darlene had given him the medicine, a tiny white pill, in a bowl of applesauce at 10 a.m. At 10:45, she ran a little experiment. She offered Sam a spray bottle of pet deodorizer and asked him to help her spray the couch. To his mother's astonishment, Sam did not run around the house squirting everything in sight. He stood in front of the couch and sprayed the cushions. Later, on a trip to the drug store, Sam asked if he could get a toy. When Darlene told him he would have to wait, he said, "O.K., Mom." She nearly burst into tears.
   By 2 p.m., the magic was over. The medicine was wearing off. In the car on the way to their appointment, Sam was looking at a newspaper when Darlene heard the sound of paper crumpling. She asked Sam not to tear the paper, but he couldn't stop. Soon, his whole body was in motion, feet jangling, fingers wiggling.
   That Friday, in Fairbanks's cramped office, the family squished next to one another on the psychiatrist's couch, all of Darlene and Brian's hopes and fears came spilling forth. They wondered aloud how they might channel Sam's impulsiveness and lack of fear. He could be an explorer, Darlene suggested. An astronaut, Fairbanks chimed in. "I want him to be a leader," Brian said finally. "I want him to follow his dreams." Later, they took Sam out for pizza in the city, a rare treat. "I am starting to go on Ritalin," he announced. "They're these little tiny pills. They're for to help me." Help you with what? I asked. "To help me with helping," he replied, as if this were the most obvious thing in the world. "With helping and listening." Then a bus rumbled by on Broadway, and Sam turned to look. Soon, he was out of his seat, darting for the door, his father calling out after him. It would be another 15 hours before his next little white pill.
   It was a difficult summer -- "a roller coaster," in Brian's words. The trial followed a complicated double-blind crossover pattern, with the doses, and hence Sam's behavior, changing week to week. While outside experts charted Sam's responses, Sam's parents and doctors were kept in the dark. Darlene, though, wasn't fooled. The week Sam played Boggle Jr., a spelling game, for 30 minutes, was a high-dose week. The week he opened the childproof bottle of Clorox and accidentally doused himself in bleach ("I wanted to help you with the laundry," he told Darlene) was the placebo week.
   By September, things had grown even more complicated. During a high-dose week, Sam developed a tic -- a common and disconcerting side effect. It began subtly, an odd, occasional rolling of the shoulder, as though Sam were trying to wriggle out of his shirt. It didn't bother him, or his parents, until a few days after Labor Day, during a family trip to Cape Cod. They were eating lunch when Darlene spotted Sam's arms going, first his left, then his right. His eyes grew big; his expression went blank. When she asked Sam to squeeze her hand, he couldn't; his own hand was curled up in a feeble knot. For two hours, Darlene and Brian watched their son deteriorate until, just as suddenly as it began, the twitching subsided. Frightened, they temporarily stopped the medication.
   These kinds of reactions, Greenhill says, are just what his team is looking for, although the cause of Sam's tic remains unclear. It could be a side effect that goes away when the child stops taking the drug. Or Sam may have a tic disorder, which sometimes occurs alongside A.D.H.D. And there is also another, more troubling possibility, Fairbanks says: "Does the medicine somehow release something that was a vulnerability? And will it continue after the medication is stopped?"
   The tic prompted Fairbanks to ask Sam's parents if they wanted to withdraw him from the trial. But Darlene and Brian, who once worried so much about putting their son on medication, did not want to take him off. "It's too soon to give up," Brian said. Today, Sam takes his optimal -- and much lower -- dose. The occasional shoulder roll remains.
   Fairbanks has seen this kind of determination before. The parents of two of her patients were crushed when their children had to leave the trial because of appetite loss and insomnia, side effects of the medication.
   In his own way, Sam seems to sense his parents' dilemma. On the drive back to Connecticut after a recent visit with Dr. Fairbanks, he pointed out the George Washington Bridge and talked about the pumpkin garden he had planted. Then he declared that he had become a parent. "I have a child," he said, in his serious, earnest way. "His name is Billy. He just turned 3. He knows all his alphabets. He knows at school when recess time is on. He knows when the bell rings, and they're going out. He listens to his teachers. He cleans up when he's supposed to." It did not take a child psychiatrist to figure out that, in his imagination, Sam had neatly created the boy he hopes to be.

Judge: Detox Doctors Not Negligent
Linda A. Johnson, Associated Press- 11/18/2002

TRENTON, N.J. -- Two doctors who practiced a method of rapidly detoxifying narcotics addicts were not negligent in the deaths of seven patients, but their licenses should be briefly suspended, a state judge has ruled. Prosecutors had charged Drs. Lance Gooberman and his assistant, David Bradway, with gross and repeated malpractice, negligence, incompetence and professional misconduct. Prosecutors were seeking to revoke their medical licenses. The charges were filed after the deaths of seven of the more than 2,350 heroin and other addicts Gooberman and Bradway treated from May 1995 to September 1999 at U.S. Detox Inc. in Merchantville. The doctors denied any wrongdoing.
   After a lengthy trial, Administrative Law Judge Jeff S. Masin ruled late Friday that the prosecution had not proved any serious charges, saying the doctors generally acted in good faith. He recommended that each have his license suspended for six months for violations of several medical standards, followed by two years' probation during which their records would be reviewed, particularly if they resumed the rapid detoxification treatments. The violations include inadequate record keeping, in some cases encouraging some patients to allow their cases to be described in publicity materials for the business and not telling early patients that the procedure was considered experimental.
  Gooberman said Monday he plans to challenge those findings. ''I'm really excited about the decision,'' he said. ''It vindicated rapid detoxification. It was important for me to hear that we didn't hurt anybody and we acted in good faith.''
   The state attorney general's office is reviewing Masin's ruling to determine whether to file any exceptions. Masin also recommended that Gooberman pay a total of $11,500 in civil penalties, Bradway pay a total of $14,000 in civil penalties, and they together pay one-third of the costs for investigation of the case by the state Board of Medical Examiners. The board polices doctors licensed in the state and must review Masin's ''initial judgment.'' It can accept his findings, reject them or modify them.
   In his ruling, Masin wrote that there was nothing intrinsically ''inappropriate or especially dangerous'' about the doctors' rapid opiate detoxification procedure. It uses medications to rapidly flush drugs out of addicts' bodies while they are under anesthesia for about four hours, getting them over the worst of withdrawal symptoms such as diarrhea, cramps and tremors that normally would last for several days. The method has been widely used in Europe and Israel, but is relatively new in the United States. Doctors in six states offer the treatment. Gooberman and Bradway have been barred from performing the procedure since September 1999. The trial began in January 2001 and continued through June 2002.
   On the Net: http://lancegooberman.com/

Michigan Closing State Mental Hospital
Amy F. Bailey, Associated Press- 11/19/2002

LANSING - One of Michigan's four adult mental hospitals will close next year, sending about 250 patients to other facilities or programs, the state health department said Monday. The state has been planning to close the Northville Psychiatric Hospital by 2006, but it expedited the closure after more than 100 of the facility's 540 Workers took an early retirement offering by the state, said Geralyn Lasher, spokeswoman for the Department of Community Health. "It made more sense to close the facility now," she said. The hospital serves adults from Livingston, Monroe, Shiawassee, Washtenaw and Wayne counties.
   Mark Reinstein, president and CEO of the Mental Health Association in Michigan, said that without the Northville hospital, the state won't have enough facilities for people suffering from a mental illness. "It's not something that the
state should be doing at this point," Reinstein said. "Even with Northville there weren't enough beds."
   After Northville's closure -- expected by July 2003 -- the state will have three adult mental health facilities: Walter Reuther Psychiatric Hospital in Westland, Kalamazoo Psychiatric Hospital in Kalamazoo and the Caro Center in Caro. The state's other mental health facilities are the Mount Pleasant Center for people with developmental disabilities and the Hawthorn Center in Northville for children.
   Additional community-based programs throughout the state and the development of psychotropic drugs reduce the need to institutionalize people with mental health disabilities, Lasher said. Depending on patients' treatment plans, they will be transferred to another instittion, group home, community-based treatment program or home with their families, Lasher said.
   In August, the Michigan Protection and Advocacy Service filed a lawsuit accusing state workers of inappropriately discharging patients from the Northville hospital earlier this year. A hearing for the case is scheduled next week in Ingham County Circuit Court. In one case, a man didn't receive the constant supervision he needed and died after suffering a heart attack because he ate too much, said Mark Cody, senior attorney for the advocacy service. "The plans weren't being developed and those that were developed weren't implemented," Cody said. "We said, `Look, these aren't going well, there are problems.'"
   Dave L LaLumoa, director of the Michigan Association of Community Mental Health Boards, said he thinks there's enough time before the Northville facility closes to find a place for every patient. "The key to this is to make sure that there's a plan in place for each of the residents so no one is left on the street," he said
   The Department of Community Health on Monday provided certification of Northville's closure to the state Legislature. In March, the closure plan will be submitted to House and Senate appropriations committees. State Rep. Virgil Bernero, a Lansing Democrat, said the department is going back on its promise to lawmakers to keep the hospital open for three years after it sold the property around the hospital. Bernero said he would have preferred the department hold off on any closures until Gov.elect Jennifer Grahholm takes office January 1.

A Boy, a Mother And a Rare Map of Autism's World
Sandra Blakeslee, New York Times- 11/19/2002

LOS ANGELES - Tito Mukhopadhyay sits in a darkened laboratory, pointing at flashes of light on a computer screen. On his right is a neuroscientist, one of several who are testing Tito's ability to see, hear and feel touch. At his left, Tito's mother, Soma, watches quietly. Tito, who is 14, often stops the testing with bursts of activity. His body rocks rhythmically. He stands and spins. He makes loud smacking noises. His arms fly in the air as if yanked by a puppeteer. His fingers flutter. Everyone waits. Tito reaches for a yellow pad and writes to explain his behavior: "I am calming myself. My senses are so disconnected, I lose my body. So I flap. If I don't do this, I feel scattered and anxious."
   Tito has severe autism, a disorder that occurs when the brain mysteriously fails to develop normally in infancy and early childhood. Born and raised in India, Tito speaks English with a huge vocabulary. His articulation is poor, and he is often hard to understand. But he writes eloquently and independently, on pads or his laptop, about what it feels like to be locked inside an autistic body and mind.
   "Tito is a window into autism such as the world has never seen," said Portia Iversen, a cofounder of Cure Autism Now, a Los Angeles research foundation that brought Tito and Soma to the United States in July 2001 and continues to support them. Autism experts are studying him, amazed to discover, for what they say is the first time, a severely autistic person who can explain his disorder. "Tito is for real," said Dr. Michael Merzenich, a neuroscientist at the University of California at San Francisco Medical School, who has run extensive tests on Tito. "He unhesitatingly responds to factual questions about books that he has read or about experiences that he has had in detail and in high fidelity." "I've seen Tito sit in front of an audience of scientists and take questions from the floor,"said Dr. Walter Belmonte, a neuroscientist and an autism expert at Cambridge University. He taps out intelligent witty answers on a laptop with a voice synthesizer. No one is touching him. He communicates on his own."
   Nor is Tito a savant, an autistic person with a single extraordinary talent like the mathematically gifted character in the movie "Rain Man." "Tito thinks and feels and has opinions '" like all the rest of us," said Dr. Samuel Smithyman, a psychologist in Los Angeles who is Tito's personal analyst. "He defies the assumptions we have about autism."
   Tito was assessed with well-validated diagnostic tests and meets all the criteria for autism, said Dr. Sarah Spence, a pediatric neurologist at the University of California at Los Angeles. Like many autistic children, Tito appeared to develop normally. He learned to sit and walk like other babies. But by the time he was 18 months old, he was showing signs that he was not like other toddlers, especially in the way he distanced himself from social settings and did not talk. After his severe autism was diagnosed at age 3, Soma decided to educate him anyway, using methods she would make up as she went along. "I saw that Tito had very good memory with roads, position of objects in the room, and also he would make complex patterns with match sticks," said Soma, as she pr-fers to be called. "I just wanted to divert his interests toward communication and learning."
   For 10 years, she and Tito lived in small apartments in Mysore and Bangalore, where she taught him, day and night. Although Tito wanted to hide in a corner and watch a ceiling fan, Soma took him for daily walks amid the colors, smells and sounds of local markets. Tito's father, who lived and worked in a distant city, visited occasionally. Soma first taught Tito to recognize letters and sounds on an alphabet board, choosing English over more difficult Indian dialects. Then she tied a pencil in his hand and showed him how to make each letter, often refusing to let him eat until he could do so.
   Around then, a method called facilitated communication, in which a parent or teacher holds the wrist of an autistic person as he or she taps messages on computer keys, had been widely discredited. Critics said teachers were prompting autistic people to respond through a kind of Ouija board effect. "I was desperate to show people that Tito's poems came from him and not me," Soma said. "I put myself in other people's shoes and knew we needed genuine proof that he could write independently." The mother also read Tito stories and books -- Aesop's fables, Thomas Hardy novels and the complete works of Dickens and Shakespeare -- and demanded that he write his own stories in return. Tito continues to write poetry and essays every day. His first book, "Beyond the Silence," was published two years ago in Britain by the National Autistic Society. "I need to write," he said recently, scrawling the words on a yellow pad. "It has become part of me. I am waiting to get famous."
   Since traveling to the United States, Tito has visited six laboratories for neurological testing. Because he cannot hold still long enough for brain imaging, he cannot offer researchers pictures of his mind in action. Instead, he gives them clues about his mental states in poems and essays that can then be explored in specially created tests. "When I was 4 or 5 years old," he wrote while living in India, "I hardly realized that I had a body except when I was hungry or when I realized that I was standing under the shower and my body got wet. I needed constant movement, which made me get the feeling of my body. The movement can be of a rotating type or just flapping of my hands. Every movement is a proof that I exist. I exist because I can move."
   Tito seems to lack a sense of his own body, the kind of internal map, Dr. Merzenich said, that normal children develop in their first few years. The maps involve brain regions that specialize in the sense of touch and movement and are widely connected to other areas, and they are highly dynamic throughout life, changing in response to everyday experience.
   By imaging the brains of higher functioning autistic people who can stay still in scanners, researchers in the laboratory of Dr. Eric Courchesne at the University of California at San Diego found that autistic people had mixed-up brain maps. Although a normal person, for example, has a well-defined brain area that specializes in face recognition, some autistic people have face-recognition areas in parts of the brain like the frontal lobes, where no one had dreamed they could be laid down. The same is true of maps that help plan movements. This means body maps are formed in autistic children, but they may be scrambled differently in each person.
   In imaging experiments starting at the University of California at San Francisco, Dr. David McGonigle, a radiologist, is exploring the hypothesis that some autistic children may have scrambled body maps. Many cannot identify parts of their bodies in a mirror. Even if they know "nose," for example, when asked to point at the nose they may put a finger to an ear, They also tend to be clumsy. With eyes closed while standing, they wobble and stagger. Ms. Iversen, whose 10-year-old son, Dov, is severely autistic, notes that maps for face recognition form early. "I smile, you smile, and maps are formed," she said. But if you do not have a faithful mental map of your own face and body, she said, you cannot read the expression on someone else's face.
  The inability to interact socially is a core problem in autism. People who lack normal body maps may not be able to build consistent mental models of the world, Dr. Bel-monte said. They may not be able to integrate sights, sounds, smells, touches and tastes. This is what Tito is talking about when he writes that he cannot perceive the world with more than one sense at a time. "I can concentrate either at what I am seeing or what I am hearing or what I am smelling," he wrote, not long after he began meeting neurologists. "It felt nothing unnatural to me until I realized that others could simultaneously see and hear and smell."
   In Dr. Merzenich's lab, Tito has had extensive testing to explore his unusual perception. Sitting in a darkened room, he listens to beeps followed by flashes of light on a computer screen. Most people can sense the sound and the light, even when they are separated by only a fraction of a second. But unless the light follows the sound by a full three seconds -- an eternity for most brains -- Tito never sees it. "I need time to prepare my ears," he told Dr. Merzenich. "I need time to prepare my eyes. Otherwise the world is chaos."
   Tito says that people with autism, at least those who are like him, choose one sensory channel. He chose hearing. Most of the time, Tito attends to the sounds of language and to oral information, which may help explain his gift for poetry. Vision, Tito said, is painful. He scans the world with his peripheral vision and rarely looks directly at anything. Other autistic people like Dr. Temple Grandin, a professor at Colorado State who earned a doctorate in animal science, spe-cializes in vision. "When I talk about anything new, I have to look at the picture in my mind, and then language narrates it like a slide show." Dr. Grandin said when she met Tito in Dr. Merzenich's lab, where they were tested side by side in September.
   For Tito, willing his body to do things is a particular problem, Soma said. "If he's sitting on the couch and I ask him to go to the kitchen, he cannot do it," she added. "But if he hears me open a bag of cookies, he moves like a gazelle on pure impulse." That is another sign that Tito's brain is disconnected, Dr. Merzenich said. Children gradually develop higher circuits to control their impulses as the frontal lobes mature and connect to circuits that developed earlier. Each stage rests on earlier circuitry; if that is abnormal, later-to-develop regions may never be organized correctly.
   Still, Tito's behavior and writings dispel a popular notion that autistic children do not feel empathy, Ms. Iversen said. Tito has feelings and notices emotions, she said, but he can be stoic about his disorder. When a mother at a large autism meeting asked Tito for his advice to parents, Tito replied simply, "Believe in your children."
   Most experts say they believe that abnormalities in several genes contribute to developing autism, along with environmental factors that have yet to be fully identified. Many parents say the first symptoms, like the lack of eye contact, as in Tito's case, do not appear for about 18 months. This accident of timing has led some to associate vaccines given at that age with the onset of autism. But it is equally plausible, many experts say, that the symptoms appear at that time because that is when the brain naturally reaches new levels of complexity. If primary sensory regions like the auditory cortex have prenatal defects, entire pathways of subsequent brain organiza-tion would not form properly.
   Researchers have measured swarms of electrical discharges in the primary hearing regions of autistic children while they sleep. Such epilepsy-like activity may affect the way the brain organizes its circuitry in childhood. Others note that the brains of autistic children are larger than average and that the brain's basic building blocks, called cortical columns, contain many more cells than normal and make excess connections to other cells. Such hyper-connectivity may cause autistic children to become overwhelmed by details because their minds are never free to integrate the whole picture. Moreover, their brains are wired in such a way that they are prone to associate things that do not normally go together. Tito says that at 4, he was looking at a cloud when he heard someone talking about bananas. It took him years to realize that bananas and clouds were different.
   As researchers continue to study Tito, Soma works with a small number of children in Los Angeles to see whether her teaching methods can help others. Unlike many educators who try to slow things for autistic children, Soma demands rapid responses, which she says prevent the child's brain from being distracted. It is too soon to tell whether she will succeed. But parents like Ms. Iversen have been impressed. When her son first used the spelling board, Dov broke his muteness, asking far a navy blue blazer and algebra lessons. When she asked him what he had been doing all those years when he couldn't communicate, he pointed out letters to spell "listening."

The Mind Tree
Maybe it is night
Maybe it is day.
I can't be sure
Because I am not yet feeling the heat of the sun.
I am the Mind Tree.
When I had been gifted this mind of mine
I heard "his" voice very clearly.
"To you I have given this mind
And you shall be the only kind
No one ever will like you be
And I name you, The Mind Tree."
I can't see or talk.
Yet I can imagine.
I can hope and I can expect.
I am able to feel pain, but I cannot cry.
So I just be.
And wait for the pain to subside.
I can do nothing but wait.
My concerns and worries
Are trapped within me somewhere in my depths.
Maybe in my roots
Maybe in my bark.
When "he" comes next, who gifted me my mind
I shall ask him for the gift of sight.
I doubt his return and
Yet hope for it
Maybe he will
Maybe he will not.
TITO MUKHOPADHYAY

Two Perspectives on Suicide
John Langone, New York Times- 11/19/2002

"No Time to Say Goodbye: Surviving the Suicide of a Loved One," by Carla Fine, Broadway Books, $12.95.
"How I Stayed Alive When My Brain Was Trying to Kill Me: One Person's Guide to Suicide Prevention," by Susan Rose Blauner, William Morrow, $24.95.

Whether a calculated ultimate protest or a depression-blinded act, suicide is what it is, a desperately arrived at dead end. For the person tormented by the obsession, it may mean numerous attempts, psychiatric wards and mood-altering drugs. For the victim's loved ones, it is a source of confusion and questions of lingering grief, guilt, shame and anger.
   These helpful books deal with suicide, the eighth leading cause of death in the United States, from two perspectives. Ms. Fine looks at those left behind; Ms. Blauner looks inward at someone who survived 18 years of suicidal obsession and three suicidal gestures. Each does much to lighten the anguish that suicide and contemplating it spawn.
   Ms. Fine's husband, a doctor, killed himself on his examining table with a powerful anesthetic. Unable to confront the circumstances of his death openly, the author told most people that he died of a heart attack. Her book takes readers from the initial impact of the suicide, when "the world explodes," through the search for explanations. It culminates in ways to make "sense of the chaos."
   With acceptance and acknowledgment of the anger that many survivors feel at being rejected by a loved one, she is able to conclude, "Unlike our loved ones, whose pain was so enveloping that they were unable to hear our shouts of help, we refuse to be exiled by despair." For Ms. Blauner, "letting go of suicide was the hardest thing I've ever had to do." For one thing, she points out, most suicidal thinkers tend to romanticize their deaths by suicide, failing to realize that any gesture or attempt can result in permanent physical damage. "The fantasy of killing myself remained strong because it was a habit, an addiction," she wrote. "I spent hundreds of hours planning my funeral and imagining the remorse of my family and friends."
   Though she concedes that suicidal thoughts may be with her for the rest of her life, she has persevered, learning how to "outthink suicide" with a wide variety of techniques. They include developing an understanding of how the nervous system works, learning to recognize what sets off feelings, knowing how and when to ask for help, keeping a journal and designing a crisis plan. The crisis plan is "a recipe for survival intended to "keep you safe when your brain starts flipping out." It includes telephone numbers of people who have agreed to be part of the plan and a list of, activities that should be adhered to -- making a gift for someone, taking a walk, playing word games, blowing soap bubbles and playing with the cat.
   Asking someone to listen on call can be difficult and embarrassing, the author says, but the person's acceptance brings hope and connection. She advises asking: "Could I put your name on my phone list? I just need you to listen, rather than offer answers or advice. I just need support." If a potential listener says no, Ms. Blauner says, "thank him or her for being honest and take several deep breaths." "You might feel rejected, which stinks," she adds, "but it just means there's someone more suitable to ask."

D.C. Mental Health Set To Lay Off About 235
David Nakamura, Washington Post- 11/20/2002

The District's Department of Mental Health will lay off as many as 235 employees in January, in an effort to streamline services and reduce costs at the nascent agency, officials said yesterday. The reduction in force, which could represent as much as 12 percent of the department's 1,935-member staff, is part of an ongoing plan to overhaul the way the city serves its mentally ill, said Mental Health Director Martha B. Knisley. "We're looking to create a sound mental health structure," Knisley said. "This has been underway for two years. We're going through a wide-ranging, sweeping review." She said the reductions will take place "across all of our operational components, management and non-management. We examined all 1,900 jobs and asked, 'Is this job critical and necessary?' "
   Last month, the D.C. Council closed a $323 million deficit by passing eleventh-hour legislation that raised some taxes and slashed the budgets of major agencies. Knisley said her department's budget was reduced from $227 million to $217 million, but she stressed that the reduction in force is not directly related to that budget crunch.
   Council member Jim Graham (D-Ward 1), who serves on the council's Committee on Human Services, said he was not aware of the pending layoffs. He said he is concerned that the city's budget problems will mean that "this is the type of thing we can expect more of rather than less."
   The city's Department of Mental Health was born 1 1/2 years ago out of a court settlement intended to end one of the nation's longest-running lawsuits on mental health care, filed in 1974, that charged the city was doing little more than warehousing its mentally ill at St. Elizabeths Hospital. A series of monitoring efforts ended with the court-ordered takeover of the system by a receiver in 1997. In May, Mayor Anthony A. Williams (D) officially took control of the department and its services for 8,000 city residents.
   As part of the transition from receivership, the department agreed to a plan that called for a reorganization, splitting its regulatory and oversight functions from its role as a provider of direct care. "In order to implement the plan, we have been restructuring continuously since the department was created," Knisley said. "One of the features of the restructuring is a focus on how we can become more efficient and streamline operations, so we can serve more people and improve the quality of care."
   Peter J. Nickles, the lead attorney whose class-action suit has represented thousands of city mental health clients since 1974, said yesterday that he had received assurances from the District that the layoffs would not adversely affect services. "If they do, we'll be back in court in a minute," said Nickles, who is to appear with mental health officials in U.S. District Court today before Judge Norma Holloway Johnson for a regularly scheduled update on how the department is progressing.
   Knisley said the layoffs were announced to the employees this week so that they would have time to find new jobs in city government or elsewhere. "We wanted to make sure we got the most information out as quickly as we can so they can plan for the short term and long term," Knisley said. Knisley noted that the department, while laying off employees, is still expanding some services, particularly in the child mental health area and treatment for the effects of terrorism. Much of the expansion is being funded by federal grants, she said.

Psychotherapy Shows a Rise Over Decade
Erica Goode, New York Times- 11/20/2002

The number of Americans who received psychotherapy increased slightly from 1987 to 1997, according to a large national study, and rose significantly for two groups: older adults and the unemployed. But the average length of time patients spent in the consulting room dropped precipitously over the same period, the study found, and the percentage of patients who combined psychotherapy with psychiatric medication nearly doubled.
   The researchers said the findings reflected the impact of managed care and the growing popularity of brief forms of psychotherapy, as well as the wider use of antidepressants and other drugs to treat many mental disorders. But the study's results, they said, also indicated that despite these changes, access to psychotherapy had increased for some groups, and that talk therapy remained, for many people, an important component of mental health treatment.
   "With all the attention given to antidepressants and other medications, the role of psychotherapy can be easily overshadowed," said Dr. Mark Olfson, an associate professor of clinical psychiatry at Columbia University and the lead author of the study, which appeared in the November issue of The American Journal of Psychiatry. "But these findings make clear that psychotherapy continues to play an important role in the mental health care of many Americans." The study, based on data collected in two national surveys by the federal Agency for Healthcare Research and Quality, is the largest to examine the patterns of psychotherapy use over time.
   Dr. Olfson said talk therapy represented a smaller proportion of all mental health treatment in 1997 than in 1987. But in absolute numbers, psychotherapy's popularity remained steady, and even experienced a slight increase. In 1987, 7.85 million people -- or 3.24 percent of the nation's population -- visited mental health professionals for psychotherapy, the study found. Ten years later, that number had risen to 9.69 million or 3.59 percent. The increase was not statistically significant, the researchers said.
   In contrast, the researchers noted large increases in the use of psychotherapy among people from the ages of 55 to 64, a little over 836,000 or 3.92 percent of whom received psychotherapy in 1997 compared with 455,000 or 2.02 percent in 1987. The number of unemployed adults making visits to mental health professionals also rose significantly, to close to 3 million or 4.62 percent in 1997 from 2.2 million or 3.33 percent in 1987.
   The new study makes it apparent , that although psychotherapy is holding its ground, few people these days undertake a lengthy sojourn on the couch. The percentage of patients who saw therapists for more than 20 sessions dropped to 10.26 in 1997 from 15.69 in 1987. Slightly over 33 percent attended only 1 or 2 sessions. The proportion of psychotherapy patients who also took psychiatric medication, on the other hand, increased to 61.52 percent in 1997 from 31.52 percent a decade earlier.
   Dr. Harold Pincus, the director of the Rand University of Pittsburgh Health Institute and an author of the study, said the same factors responsible for the increased use of psychiatric medication, including a greater public awareness of depression and other psychiatric conditions and the gradual lessening of the stigma attached to mental illness, might also be drawing more people in these groups to psychotherapy. "A rising tide raises all boats," Dr. Pincus said.
   Depression, manic-depression and other so-called mood disorders were by far the most common diagnoses given to patients who received psychotherapy in 1997. Almost 39.09 percent of the patients surveyed were listed on insurance forms as suffering from depression or another mood disorder, compared with 19.51 percent 10 years earlier.
   In a study based on the same surveys published last January, Dr. Olfson and his colleagues found that the number of Americans being treated for depression on an out-of-hospital basis more than tripled from 1987 to 1997 and the proportion of those in treatment who were taking anti-depressant drugs doubled.
   In the surveys, the participants kept diaries in which they recorded visits to mental health professionals for psychotherapy or counseling. One weakness of the study, the researchers and other experts said, was that there was no way to know what type of psychotherapy the participants received. "I think that really is an important thing to study," said Dr. Darrel A. Regier, executive director of the American Psychiatric Association's Institute for Research and Education. A variety of studies have shown that some types of psychotherapy to be highly effective, Dr. Regier noted, but "there are a lot more studies on medication than on psychotherapy."

Seattle Housing for Alcoholics OK'd
Phuong Cat Le, Seattle Post-Intelligencer- 11/21/2002

A controversial project to house chronic alcoholics -- but not require them to give up booze to get a bed -- got a green light after the city's hearing examiner ruled in its favor yesterday. Opponents last month appealed a decision by the city's Department of Construction and Land Use to grant the project a master permit. They said the project would bring public safety, aggressive panhandling and other problems to the Denny Triangle neighborhood.
   The proposed apartment building, at 1811 Eastlake Ave., has been controversial and unusual because sobriety won't be a rule for the alcoholic tenants who would live in the 75 studios. The project would tolerate drinking by tenants while providing them with housing, meals and support services to help coax them into treatment.
   "I'm looking forward to getting the project off the ground," said Bill Hobson, executive director of the Downtown Emergency Services Center, the non-profit social-service agency that will build and manage the building. "This takes the project out of the legal limbo it's been in." The $8.6 million housing project has funding from the city, county, state and federal governments. Demolition of the current building is expected to begin early next year, Hobson said.
   Meanwhile, disappointed opponents said yesterday they would figure out their next course of action. "We disagree with her (the hearing examiner's) decision," said Richard Aramburu, the attorney who represented the Eastlake Downtown Community Association, which filed the appeal. Formed to oppose it, the group comprises three businesses located near the proposed project -- Marriott Springhill Suites Hotel, Northwest Trophy and the Benaroya Co., which owns several mixed-used office towers. Members of the association worried that the project would drive away business and residents. "We're not surprised, but we're frustrated," said Robb Anderson, co-owner of Northwest Trophy. The group appealed the land-use approval, saying the land-use department didn't give adequate notice about the project and didn't properly assess the potential problems to the neighborhood, such as public urination, violence and other criminal behaviors.
   In her decision issued yesterday, hearing examiner Meredith Getches cited other housing projects, such as the Wintonia in Capitol Hill, where homeless chronic alcoholics have been good neighbors, even when they continue to drink. Although chronic alcoholics living on the streets can create problems for a neighborhood, Getches noted, those who are in housing "can be good neighbors and do not have those serious and harmful impacts on a neighborhood."
   The project is based on the "harm-reduction theory," which seeks to lessen problems such as crime and public health dangers while tolerating certain addictions. Opponents of the harm-reduction theory, however, say that it enables alcoholics to drink. Dr. Kathleen Decker, a psychiatrist who testified for opponents during the hearing, said the lack of abstinence would decrease tenants' interest in seeking treatment.
   If chronic alcoholics don't have housing, the emergency services center's Hobson said, they'll continue to live their addictions in the city's streets, parks and alleys. Hobson said tenants would be expected to follow rules of behavior similar to ones in place at four other housing projects his center runs. "It's not a silver bullet," he said, "but it's a start."

Smoking Cannabis Linked to Mental Illness
Patricia Reaney, Reuters News Service- 11/22/2002

LONDON - Smoking cannabis increases the odds of suffering from depression and schizophrenia, doctors said today. The occasional marijuana cigarette may not be harmful, but people who start using cannabis as teens have a higher risk, and the severity of the illness is linked to the length of exposure to the drug. ''Very young adolescents who use cannabis have an increased risk for developing schizoprehenia as adults and the most at risk are the youngest users,'' said Dr. Louise Arseneault, of Kings College in London.
   Doctors do not understand how cannabis increases the risk of schizophrenia and depression but they suspect it affects the dopamine system in the brain, which is associated with pleasure. It is thought the drug can trigger the onset or relapse of schizophrenia in people predisposed to the illness and may also exacerbate the symptoms.
   In a study of 1,037 people born in New Zealand between 1972-73, Arseneault found that those who began using cannabis as teens were four times more likely to suffer from psychiatric problems as adults than adolescents who did not use the drug. ''The earlier you start, the more vulnerable you are,'' she said.
   Her findings, which are reported in The British Medical Journal, are supported by two other studies in the magazine that found similar results. Researchers at the Murdoch Children's Research Institute in Victoria, Australia, found that teenage girls who frequently used the drug were more likely to suffer from depression and anxiety than other adolescents. Another study of more than 50,000 Swedish enlisted men showed the use of cannabis increased the risk of schizophrenia by 30 percent.
   Schizophrenia is the most common form of severe mental illness. The cause of the disorder, which is characterized by unusual behavior, delusions, and hallucinations is unknown but scientists say it affects chemicals in the brain.

US Drunken Driving Deaths Rise After Holding Steady in '90s
Jack Sullivan, Associated Press- 11/22/2002

WASHINGTON - The number of drunken driving deaths in the United States rose last year after holding steady during most of the 1990s, Mothers Against Drunk Driving said yesterday. There were 17,448 drunken driving deaths in 2001, up from 16,572 in 1999, the last time MADD conducted it's ''Rating the States'' survey. The organization graded the nation with a C, down from a C-plus in 1999, with California ranking the highest with a B-plus and Montana flunking. Massachusetts scored a D-minus, tying it with Alaska and ranking it just slightly above Montana. The grades are based on the number of alcohol-related crashes in each state, trends in the number of deaths, state laws on the books and enforcement efforts.
   One group, the Governors Highway Safety Association, criticized the MADD report, saying states should be judged on how they measure up against their own goals rather than against each other. MADD faulted Massachusetts' political leaders for passing less than half of the laws recommended by MADD to curb drunk driving. ''We need to do more,'' said Barbara Harrington, executive director of MADD Massachusetts. ''It is time to rekindle efforts against drunk driving.''
   The group said the first thing Massachusetts should do is pass a law mandating that any driver with a blood alcohol level above the legal limit be automatically considered drunk. Currently, state law only allows blood-alcohol levels as evidence of intoxication, rather than as proof. Juries can find drivers not guilty of drunken driving even if their blood alcohol level is above the legal limit. Massachusetts is the only state without the law; it faces the loss of millions of dollars in federal highway funds if it doesn't adopt the change.
   Advocates also criticized lawmakers for failing to pass a bill allowing police to pull over a driver and issue citations for not wearing a seat belt. Currently, drivers in Massachusetts can be cited for not using seat belts only if they are pulled over for another offense. ''When that police officer makes the stop, he or she needs the tools, as do we in the courts, to produce the evidence that that person has been driving drunk,'' said Middlesex District Attorney Martha Coakley.
   In 2001, 234 people died in car accidents involving alcohol in Massachusetts, about 49 percent of all motor vehicle fatalities, compared with the national average of 41 percent. The rate of young drivers who had been drinking and were involved in fatal accidents in Massachusetts increased between 1998 and 2001, according to the report. Nationally, alcohol-related traffic deaths dropped by 40 percent from 1980 (when MADD was formed) to 1993. The number of deaths hovered around 16,500 from 1994 to 1999.
   ''The war on drunk driving stalled,'' MADD president Wendy Hamilton said. She called Montana ''abysmal,'' noting the number of alcohol-related crashes in the state, its failure to set 0.08 percent as the legal blood alcohol limit, and a lack of support for making failure to wear a seat belt a primary traffic violation. It was the first time any state has received a failing grade. Last year, 104 of Montana's 230 traffic deaths occurred in alcohol-related crashes, MADD said.
   Dave Galt, director of the Montana Department of Transportation, said he is concerned about that number but said the state is working to lower it. He said he expects the Legislature will consider lowering the blood alcohol level from 0.1 percent next year and imposing a statewide ban on open containers of alcohol in vehicles. ''I'm not proud of being `F,''' Galt said. ''I take that very seriously.'' Galt said he disagreed with how the report described the state's efforts to fight drunken driving, pointing to funding of efforts to reduce underage drinking and to set up visible sobriety checkpoints.
   After California, other states that received high marks include Georgia, New York, North Carolina, and Oregon, which all received B grades. MADD's recommendations to reduce the number of deaths include more and well-publicized sobriety checkpoints. It also urged tougher penalties against drivers who refuse alcohol tests when stopped, are caught driving with license that was suspended for an earlier drunken driving arrest, or who have a blood alcohol level of 0.15 percent or more.

Battered Women's New Day in Court
Kimberly Edds, Washington Post- 11/22/2002

LOS ANGELES -- Marva Wallace's husband beat her. The young woman was bloodied and bruised often during her one-year marriage. Then one horrible night her husband slapped her and forced her to perform a sex act while her 2-year-old daughter watched. Afterward, Wallace went to the bedroom, got a gun and shot him three times in the back of the head. She spent the past 17 years in prison for murder, but Wallace, 48 and a grandmother, now is free. She is the first woman to be released under a new California law that gives inmates a chance to prove the outcome of their trial could have been different had evidence of "battered-woman syndrome" been presented.
   The 11-month-old law may turn back the clock on hundreds of murder convictions decided before such evidence was required to be admissible at trial. It will give abused women one last legal tool to seek a new trial, have the severity of their offense reduced or even be released with time served, said advocates for battered women.
   A few states have enacted laws over the past decade to make it easier for defendants to pursue a strategy of self-defense using battered-woman syndrome, including evidence of prior beatings. Since 1992, California has required that evidence of abuse be permitted in murder trials. But the new law is the first in the nation to allow inmates convicted in trials before the new requirements to demand another hearing.
   Wallace was convicted in 1985, and Los Angeles Superior Court Judge David S. Wesley freed her last month. It is up to prosecutors to decide whether they want to retry her; a spokeswoman for the district attorney's office said the case is under review. At a new trial, a defense expert would testify that Wallace was a victim of battered-woman syndrome. Some medical experts say a steady cycle of violence leaves women feeling helpless, so they often stay in abusive relationships and may eventually see suicide or homicide as the only way out. Advocates are hoping Wallace will not be retried and will be allowed to remain free -- a sign that the fight to free battered women is being reinvigorated. "We're definitely hoping that she is granted a release so other judges won't feel timid or shy about doing something completely new," said Nausheen Hassan, of the California Women's Law Center.
   Skeptics say evidence of battered-woman syndrome was routinely admitted in court before it was mandated a decade ago. They also say the law seems excessive, given the other mechanisms in place to ensure the convictions were just. "Our chief concern was it was unnecessarily disturbing murder convictions which were properly reached by a jury," said Lawrence Brown, executive director of the California District Attorneys Association. The association initially opposed the bill, but became neutral after securing an amendment that prevents inmates who raised the issue under different legal challenge and lost from trying again. "We were concerned about giving murderers two bites at the apple," Brown said.
   Sue Osthoff, of the National Clearinghouse for the Defense of Battered Women, said explaining to juries the effects of abuse is critical to showing a woman acted in self-defense. But critics label the strategy as the "abuse excuse," a blank check that allows women to kill without being held responsible for their actions.
   Advocates argue many women who kill their batterers actually endure a tougher legal road and stiffer penalties than men who beat their wives to death in the heat of the moment. Having an expert witness help explain why abused women may feel in imminent danger even when their partner is not actively attacking them can be a turning point for the defense, they said. "Most people can understand self-defense if I'm attacking you, but they don't understand how someone who after years of terror, shoots them in the back or poisons them, is acting in self-defense," said Kenneth Theisen, a lawyer with the California Coalition for Battered Women in Prison.
   Nearly 600 women are in California prisons for killing their alleged batterers, but it is unclear how many of those women were convicted prior to 1992. Advocates said at least 100 women would be entitled to seek relief under the new law. Only women convicted of first- or second-degree murder are eligible to seek relief under the new law -- leaving without recourse women who pleaded guilty to manslaughter to avoid a harsher sentence.
   Osthoff called the law a "creative" way of navigating the complex avenues California inmates must take to seek release, when clemency and parole are options that have all but been taken from them. Two weeks before Wallace was freed, she was turned down for parole by Gov. Gray Davis (D). The governor has vowed to let no murderer go free, rejecting all but two of the 144 cases recommended for parole by the Board of Prison Terms.
   The push to free battered women from prison was stepped up in the early 1990s. Several governors granted clemency to dozens of convicted killers, including Richard Celeste, then governor of Ohio, who freed 25 women, saying they had not had an opportunity for a fair trial because testimony about abuse had not been presented. But the dozens of clemency petitions sent to Pete Wilson, who was then California's governor, went largely unanswered. Three women out of 34 petitions submitted by battered women were freed -- for reasons other than their abuse. Initially receiving a swell of public attention, the campaign has lost momentum. Few women have been freed in recent years.
   Advocates say they hope the California law can once again jump-start the effort across the nation -- and there are some signs of movement. New York, which has not freed an alleged battered woman since 1996, adopted a law in July that allows victims of domestic violence serving prison terms for killing or assaulting their abuser to be eligible for work release.

What Did You Mean by All That, Dr. Freud?
Richard Panek, New York Times- 11/24/2002

Some six decades after his death, a century after the publication of "The Interpretation of Dreams" and an eternity since we've been able to imagine what living in a world without Freud might have been like, the question can seem nonsensical. But over the years Freud's chroniclers have taken such radically opposite approaches, either idealizing him or demonizing him, that even a scholar of psychoanalysis might wonder: who was he, really?
   There is no "really," Freud might have answered, and then he probably would have made the point that such interpretations reveal more about the interpreter than they do about the subject. But he would also have insisted that there exists at least the possi-bility of trying to understand an individual on his own terms. In his case, that perspective is available only now that the so-called Freud wars have, if not ended, at least abated.
   "People are ready to look at Freud with clearer eyes than ever before," said David Grubin, the writer, producer and director of the documentary "Young Dr. Freud," which has its premiere on PBS on Wednesday. "Freud was a genius, but he was also wrong about a lot of things. So let's just try to understand why he did what he did, how he did what he did, and how we've moved on." When Freud died in 1939, his reputation rested on his mature work and its consequences -- his theoretical writings on psychical structure in the 1920's and his summations of his life's work in the 1930's, as well as the spread of the psychoanalytic movement. He, was an outsize historical figure, more of a figurehead, actually: bearded, bearing a cigar, peering over rimless glasses into some recess of the psyche. Not until the 1950's, beginning with the publication of Ernest Jones's biography, selections from Freud's correspondence and, for English readers, the Standard Edition of his writings on psychoanalysis, did the pre-figurehead Freud become public.
   The response was extreme and, in retrospect, predictable. Freud was not what he seemed. He had manipulated the past in his later reminiscences, embellishing memories so that he might seem to have been the victim of an intractable medical establishment in his youth. He had manipulated the future, burning manuscripts and junking correspondence so that posterity might not have too easy a go at him. Freud was a fraud
   But this neglected the same truth that the earlier hagiographers had failed to take into account: Freud was human. "And why not?" Mr. Grubin said. "Why shouldn't he be flawed?" As he began planning his documentary, Mr. Grubin decided he wanted to avoid presenting "one polemicist versus an-other polemicist." In particular, he wondered whether he would find psychoanalysts who not only saw Freud's flaws but would also say so on film.
   Somewhat to his surprise, he did. As Elisabeth Young-Bruehl, a Manhattan psychoanalyst and a biographer of Freud's daughter Anna, told Mr. Grubin during a panel discussion last spring at the Museum of Television and Radio: "If you had made this film even 15 years ago, you would not have had a group of psychoanalysts who were as willing to be publicly critical, skeptical -- to have a historical distance from the founding father. That has changed completely within the world of psychoanalysis."
   Freud always expected to be controversial, but for what he wrote, not who he was. What he didn't anticipate -- and where his public afterlife has turned out to differ from that of other figureheads -- is how much the revelation of his human flaws would affect the perception of his entire program. If Freud fudged, if Freud imposed his interpretations on his patients, if his correspondence with Wilhelm Fliess from the 1890's reveals that Freud worshiped someone we might today call a quack -- what does that say about psychoanalysis?
   "One hundred years later, Freud's essential insight that we're driven by forces we aren't aware of, that we're not transparent to ourselves -- we just accept that," Mr. Grubin said. "Everybody accepts that." What not everybody accepts is that psychoanalysis is a science. Freud himself always insisted it was. But during his lifetime psychologists and philosophers argued otherwise, and today psychoanalysis remains controversial to the extent that its founder departed from traditional scientific methodology. Without subscribing to either view, Mr. Grubin took the nonidealizing, nondemonizing perspective now available and tried to apply into the period before "The Interpretation of Dreams," when Freud was consciously modeling his work on the scientific method. Hence the focus of the film as well as its title: "Young Dr. Freud."
   He knew this approach would present challenges, Mr. Grubin said, not just analytic but cinematic. "I'd done Napoleon right before this," he said, referring to the latest in a series of television documentaries he has made chronicling the lives of world leaders, including Lincoln, Truman, Lyndon Johnson and both Roosevelts. "Here's this one guy fighting on these battlefields. Horses. And cannons. And this other guy whose life is relatively uneventful. What's he doing every day? Seeing his patients. Having lunch. Seeing his patients. Sitting down to work. Takes his walk along the Ringstrasse; goes back to work. Day after day after day. Freud had this uneventful life -- the opposite of Napoleon's life. How do you render the great events of his life, which were internal?"
   Although he relied on reenactments to bring to life the dream images and memories that Freud described during this period, Mr. Grubin also found himself adopting "a radically different structure." While considering how to present Freud's personal story -- all that potentially deadly background blah-blah-blah about childhood and home and family, always the bane of the documentarian's existence -- Mr. Grubin realized that the Freudian approach itself offered a solution. Why not introduce the information about the early years of Freud's life not when a documentary usually would, near the beginning of the film, but instead when it becomes important, to Freud -- just as all the influences of Freud's scientific and cultural background coalesce in the late 40's, and psychoanalysis, if not the 20th century, is born?
   If this structure works, Mr. Grubin said, it will "seem that that's the way it should be." Because that's the way psychoanalysis works and, if Freud was right, that's the way the human mind works as well. "I don't think people really understand what Freud did and what analysis is," Mr. Grubin said. "If more people went into analysis because of seeing this, I'd be very pleased." Not, he said quickly, that he made "Young Dr. Freud" for that reason (at least, not consciously). "But it's a very human process. That's what people don't quite get. It's what Socrates said: 'Know thyself:' 'Not so easy': That's what Freud said."

Defending Bruno Bettelheim
A Book Review of "Rising To the Light" by Theron Raines
Emily Nussbaum, New York Times Book Review- 11/24/2002

No one falls harder than a hero, and Bruno Bettelheim fell harder than most. Before his suicide in 1990, Bettelheim was considered close to a secular saint: a gentle sage who courageously synthesized what he had learned as a survivor of the Nazi concentration camps and spearheaded a revolution in child psychology. His belief that bad mothering caused autism might have been outmoded, but he himself was still widely considered a genius, a compassionate philosopher of survival.
   Yet within weeks of his death, scandal crashed in. Patients at his Orthogenic School for emotionally disturbed children at the University of Chicago came forward with claims that far from being gentle, Bettelheim slapped and abused his charges. His most influential book, "The Uses of Enchantment," a study of the therapeutic power of fairy tales, was said to be marred by plagiarism. And seven years later, a truly devastating biography was published: "The Creation of Dr. B," by Richard Pollak, whose brother had. been a patient of Bettelheim's. The notoriously private psychoanalyst had refused to be interviewed, but Pollak worked for years tracing his history. His conclusion was that Bettelheim was not just a bully but an inveterate liar who faked his academic career, his concentration camp experiences and the evidence for his school's success.
   Given this history, one can sympathize with Theron Raines's obviously heartfelt desire to reclaim his friend and client's reputation. His is not the first defense of Bettelheim. Nina Sutton covered much of the same ground in "Bettelheim: A Life and Legacy," making many of the same psychoanalytically inflected arguments. But Raines's perspective is more explicitly personal.
   Indeed, he is open about his hero worship. For years, Raines, who was Bettelheim's literary agent, had been taping interviews with him, aiming to put them together either as transcripts or as a sort of collaborative autobiography. Such interviews took place up until three days before Bettelheim's suicide-- a source of much anguish for Raines, who was devastated at the thought that he might have saved his friend.
   This intimate source material could have made "Rising to the Light" uniquely illuminating, a book that offered, in effect, Bettelheim's response to his critics from beyond the grave. But no matter how many interviews Raines conducted, Bettelheim withheld meaningful details -- alternately talking about his life in the abstract, distanced manner in which he wrote about it, and delivering canned (and sometimes questionable) anecdotes familiar from earlier biographies. In all their conversations, Raines notes, Bettelheim revealed "not a single vivid anecdote about life at the Orthogenic School." He was also unwilling to discuss his first marriage, his relationships with his children or his months at Dachau and Buchenwald.
   Raines interprets this opacity with radical charity, insisting that Bettelheim is protecting his privacy, refusing to revisit a painful experience or modestly avoiding bragging. A less charitable interpretation might be that Bettelheim kept his stories vague in order not to trip himself up or, more generously, that Raines was simply unwilling to press an elderly, depressed man on the hard questions. Whatever the explanation, the end result is that the book suffers from many of the same flaws as Sutton's 1998 biography: Raines is so determined to rehabilitate Bettelheim's legacy that he fills in the gaps with his own sympathetic readings, then accuses people who disagree of projection, sour grapes or both.
   Most strikingly, Raines fails to confront in any meaningful way Pollak's findings. Rather, he relegates these issues to the footnotes and appendixes, particularly the odd Appendix D, titled "Eidetic Memory and False Memory (and Autism)," in which he explains that a certain amount of image embellishment "no doubt happens within all of us." But the stories Bettelheim is accused of faking go beyond simple self-dramatization. He claimed, for example, that he met Freud; that Eleanor Roosevelt helped with his release from Buchenwald; that he participated in the Jewish resistance; that he raised two (or sometimes "several") autistic children with his first wife. When Raines does provide Bettelheim's version of one of these tales (for instance, Bettelheim's memories of a young American girl he and his wife took in), there is sparse comment on other stories Bettelheim provided on the subject.
   Raines also uses Appendix D to dismiss Pollak's other major assertion: that Bettelheim exaggerated the successes of the Orthogenic School. We should take it on faith, Raines says, that the doctor cared more about the children than statistics, and thus had good reason to object to follow-up studies: to do so would violate "the understanding -- the covenant -- the school had with the children. Given the questions about Bettelheim's truth-telling, this is an unpersuasive argument.
   Raines does, however, deal fully with Bettelheim's habit of hitting students. Indeed, he returns to the subject again and again. The Sonia Shankman Orthogenic School was (as even critics acknowledge) in many ways the revolutionary place Bettelheim portrayed in his writing: a homey environment in which severely disturbed children were treated with patient love. But while counselors were forbidden to hit their charges, Bettelheim habitually slapped students. He humiliated his young, inexperienced staff members, a method one staff member memorably termed "the Nazi-Socratic method." Worshiped and feared, he was the very model of a charismatic, intimidating autocrat.
   Raines's response to this is tautological: Bettelheim was a genius, so if he hit children, he must have had good reason. Bettelheim was the school's "super-ego," Raines says, its master, its symbolic father. (Rather confusingly, he also says that Bettelheim hit children precisely so they wouldn't see him as a father.) Only a physical attack could break through the children's "false dignity" and help them to rebuild their damaged personalities.
   Raines's faith in Bettelheimn is so extensive that he appears at times to regard the doctor as godlike: "The iron in Bettelheim's spirit gave weight to his hand in raising barriers of fear, and his insight into a child's motives told him the moment to do what he did." Why, then, did Bettelheim not mention slapping in his several written accounts of the Orthogenic School -- speaking out many times against physical discipline, calling it at, one point "a brutal and illogical method"? Again, Raines finds a selfless explanation: "Rather than courting misjudgment on all sides, he chose to act for the children and leave the world in the dark."
   Raines takes a similarly defensive tack on other controversial subjects, like Bettelheim's mother-bashing and his theories of Jewish passivity in the face of the Holocaust. For Bettelheim scholars, there is some fresh information here, as when Bettelheim discusses in detail his early years with a wet nurse, as well as his early intellectual influences. But almost all of the basic material is familiar from either Bettelheim's own writing or earlier biographies. Indeed, Pollak himself used an earlier version of Raines's manuscript, although he presented the material more critically. Several resources were simply not available to the author: when he interviewed, Bettelheim's first wife, Gina, she spoke to him for 30 minutes, told him he was "too close" to his subject, and ended the interview.
   Strangely, despite its darker portrait, one may in the end develop a more sympathetic sense of Bettelheim's life from Pollak's biography, which often acknowledged opposing perspectives, including those of children who felt they benefited from his care. For while Raines clearly loved and admired Bettelheim, his insistence on the Bettelheim's genius is so hyperbolic it eventually grows unconvincing. Bettelheim's "mental stance ... reminds me of classical Greek sculpture, where gods and mythic heroes stand before us naked and natural," Raines writes, and even Bettelheim's suicide is judged "an act typical of him in its clarity, courage and rationality."
   If this worshipful portrait does not repair Bettelheim's damaged reputation, Bettelheim is at least not alone. Alfred Kinsey; Dr. John Money (the subject of John Colapinto's "As Nature Made Him: The Boy Who Was Raised as a Girl"); Carl Jung and Freud himself -- each of these heroes of psychoanalysis and psychology has been tilted off his pedestal in recent years. But if these debunkings may feel at times like little murders; they are also perhaps necessary correctives, reminders that even the most charismatic intelligence is no guard against human weakness.

Mentally Ill Children Unable to Get into Treatment Centers
Associated Press, 11/24/2002

HARTFORD, Conn. -- Children diagnosed with serious psychiatric problems face a shortage of state beds, and often are housed in emergency rooms while waiting for space at an appropriate facility, The Hartford Courant reported Sunday. The problem has grown worse in the past two years, and children are waiting longer for admission to psychiatric care centers, the newspaper reported. Last month, Connecticut Children's Medical Center's emergency room doctors held children awaiting psychiatric beds for 60 days. In October 2001, children were held in the emergency room for 18 days. In 2000, the total was only five days.
   ''It's just out of control,'' said Dr. Lynelle Thomas, director of Yale-New Haven Hospital's emergency child psychiatric service. The hospital has seen the number of patients receiving psychiatric assessments jump from 500 in 200 to 720 in 2001. ''We're admitting kids from the psychiatric unit to our pediatric medical unit,'' she said. ''It's completely inappropriate, but we're in a crisis.''
   During the past two years, there has been a constant waiting list at the 98-bed Riverview Hospital in Middletown., the state's only youth psychiatric hospital. Children who are ready to leave that facility often cannot because there are not enough sub-acute programs for them to move into, the newspaper reported. ''This is not a new problem. This is a recurring problem,'' said state Child Advocate Jeanne Milstein.
   The Department of Children and Families had one program, St. Francis Care Behavioral Health in Portland, where children could go post-hospitalization. But the agency ended its contract two months ago after a dispute about how the facility treated patients. The decision eliminated 75 beds for sick youths.
   ''There's not enough beds in the community, so where else are they going to go? To America's safety net: the local emergency department,'' said Dr. Peter Jacoby, chairman of the emergency department at St. Mary's Hospital in Waterbury. ''They can always come through our door and we have to stabilize them and make sure they're safe.''
   DCF has tried to address the problem through a program called Connecticut Community KidCare. In its first year of operation, mobile crisis teams dispatched by the program have helped divert more than 120 children from the emergency room at Connecticut Children's Medical Center during the past year, to private beds. The program hopes to create an additional 200 mental-health beds statewide by hiring private providers. DCF spokesman Gary Kleeblatt said the initiative will take time to develop, but said the department is making ''substantial progress'' on the problem. ''KidCare in all its components will take two to four years of implementation to see the full impact,'' Kleeblatt said.