Addicts Treat Others' Overdoses
John M. Glionna, Los Angeles Times- 12/2/2002

SAN FRANCISCO -- In the newest twist in harm reduction among users of dangerous drugs, a controversial study conducted here suggests that heroin addicts can be trained to treat fellow junkies against potentially fatal overdoses. The project, co-funded by the San Francisco Department of Public Health, turned 24 longtime heroin users into enterprising street doctors, organizers say. Supplied with syringes containing the anti-overdose drug naloxone and trained in cardio-pulmonary resuscitation, the users were able to take timely lifesaving measures with a drug now available only to physicians and paramedics. The moment a companion had an overdose reaction, the trained addict injected the drug into the victim's leg or shoulder.
   Researchers from the Urban Health Study will release their naloxone study results Monday at the National Harm Reduction Conference in Seattle. The group is composed of health-care experts who specialize in such efforts as needle exchange programs for drug users. They also want San Francisco officials to consider becoming the first major city in the West to distribute naloxone. The drug is available to addicts in New Mexico and Chicago, and Baltimore officials plan to start dispensing naloxone next year.
   Proponents say naloxone is a legal, nonaddictive drug that does not produce a high or sense of euphoria. When injected into a major muscle, naloxone, commonly known by its brand name Narcan, sends overdose victims into an instant acute withdrawal. The drug works by binding to the brain receptors that normally attract opiates such as heroin, morphine or methadone. Without naloxone, heroin overdose victims often die from respiratory failure. "This drug has been shown to save lives," said Karen Seal, a physician and lead author of the 2001 study.
   But critics say dispensing naloxone to addicts as a harm reduction technique is really harm promotion. "You're putting a very serious medication into the hands of untrained people," said Eric Voth, an addiction medication specialist and chairman of the nonprofit Institute on Global Drug Policy. "The answer to heroin addiction is aggressive outreach, not an end-around against modern medicine. City officials should beware of the serious liability issues if someone dies after being administered this drug by another addict."
   Seal, an assistant professor of family and community medicine at UC San Francisco, said a citywide dissemination of naloxone would improve the lives of an intravenous drug population estimated to be as large as 14,000 to 17,000. Each year, San Francisco hospitals see more than 100 heroin overdose deaths, many of which Seal believes could have been prevented. Doing her time in the emergency room, she saw the culture of heroin while responding to as many as half a dozen overdose victims a day. She knows the futile result of street techniques used by junkies to stop a heroin overdose: everything from injecting victims with salt water or milk to immersing them in an ice bath.
   A bigger problem is that many addicts, when witnessing an overdose, are reluctant to call 911 or summon help, for fear of arrest. Two years ago, Seal set out to discover "why people could stand by a heroin overdose victim and not intervene." For six months, her study employed 12 teams of heroin addicts -- users so dependent that they no longer take the drug to get high, but rather to avoid the agony of withdrawal. After eight hours of training, participants were given kits containing vials of naloxone, latex gloves and alcohol wipes. Half were homeless. Their median age was 40 and one-third were women. The goal was for each team member to look out for the other and be on hand with naloxone if one of them overdosed. In all, the participants witnessed about 20 overdoses and used naloxone in 14 cases, resorting to CPR in the others. One participant died after injecting heroin while alone.
   Seal said researchers initially feared that they could harm addicts by giving them naloxone. "We didn't know whether they'd become vigilantes and use more heroin because they felt they had this magic anti-overdose antidote," she said. But researchers found that whereas in the six months before the study the group reported 68 overdoses, in the six months after the study only five occurred, although naloxone was no longer available. Seal said their participation led many study subjects to seek referrals to methadone clinics, although there is no evidence that the drug itself does anything to discourage heroin use.
   One participant was William Bowden. The 51-year-old Philadelphia native and longtime junkie said carrying naloxone gave him a new take on San Francisco's back-alley heroin scene. "When you're a junkie, nobody cares about you; you don't even care about yourself," he said. "But this study made me look at things differently. By being concerned about others, I became more concerned about myself."
   Seal said addicts showed researchers even more enterprise: In more than half of the 14 cases in which naloxone was used, it was administered not to the participant's addict partner but to strangers they encountered on the street. Many offered mouth-to-mouth emergency treatment to strangers who were violently ill. "They took a risk of being arrested to save somebody else," Seal said.
   San Francisco officials aren't exactly lining up behind a naloxone program for addicts. Joshua Bamberger, medical director of the housing and urban health section of the city's Department of Public Health, said other outreach efforts helped drive the city's heroin overdose deaths to a 10-year low of 101 in 2001. "It's undoubtedly worth exploring," he said of the naloxone plan. "But I don't know the political lay of the land."
   Critics remain disturbed by the image of addicts cast as lifesavers. They might mistake alcohol or cocaine overdoses and inject naloxone, delaying proper medical help. "To receive naloxone is a hellish experience," said Voth of the Institute on Global Drug Policy. "People go into instant withdrawal and often suffer vomiting, diarrhea and extreme agitation. I don't think other addicts could ever be trained to manage such an ordeal."
   Seal said study participants were trained for just such a result. "People who've been given naloxone wake up angry, and we told our participants the victim might look at them like 'Hey, you just ruined my high,' " she said. "People don't understand that they've basically died and have just been saved."
   Despite such drawbacks, public distribution of naloxone has worked in New Mexico, where a state law passed in 2001 legally protects people who inject an overdose victim with naloxone. San Francisco researchers say they would push for a similar liability law. Chicago also has seen dramatic effects since the drug began being dispensed through private clinics. "Not long ago, 466 people died in Cook County alone from heroin overdose in a single year," said Dan Bigg, executive director of the Chicago Recovery Alliance. "The people bitten by the snake of heroin addiction couldn't cope." Last year, the county saw a 20% drop in heroin-related deaths, its first. Bigg attributed that to getting naloxone onto the streets. "It works," he said. In contrast, Portland, Maine, has backed away from a plan to give naloxone to heroin users. "We got flak from law enforcement and the community -- letters and e-mails," said Gerald Cayer, the city's director of Health and Human Services.
   But drug policy experts say naloxone's time may have come. Ricky Bluthenthal, a social scientist in the health program and drug policy research center at the Rand Corp. in Santa Monica, said the federal government should encourage study of naloxone use among heroin addicts. "If you give drug users the tools that lead them to be healthy, they'll use them as intended," he said.

Study: Marijuana May Not Lead to Hard Drugs
Reuters News Service, 12/2/2002

WASHINGTON- Casting doubt on a basic principle of U.S. anti-drug policies, an independent study concluded on Monday that marijuana use does not lead teenagers to experiment with hard drugs like heroin or cocaine. The study by the private, nonprofit RAND Drug Policy Research Center countered the theory that marijuana acts as a so-called gateway drug to more harmful narcotics, a key argument against legalizing pot in the United States. The researchers did not advocate easing restrictions in marijuana, but questioned the focus on this substance in U.S. drug control efforts. "The evidence has seemed so strong in favor of the gateway effect that a lot of policy-makers and others have taken it for granted the gateway effect is real. We have shown why this is not necessarily the case," said Andrew Morral, lead author of the RAND study.
   Using data from the National Household Survey on Drug Abuse between 1982 and 1994, the study concluded teenagers who took hard drugs were predisposed to do so whether they tried marijuana first or not. "Kids get their first opportunity to use marijuana years before they get their first exposure to hard drugs," Morral said. "It is possible marijuana is not a gateway drug. It's just the first thing kids often come across." Morral said 50 percent of U.S. teenagers had access to marijuana by the age of 16, while the majority had no exposure to cocaine, heroin or hallucinogens until they were 20. He said this four-year gap in exposure to the drugs raised doubts about the gateway theory espoused by many social scientists, and underpinning many U.S. anti-drug policies and education campaigns.
   The study, published in the British journal Addiction, does not advocate legalizing or decriminalizing marijuana, which has been linked to side-effects including short-term memory loss. But given limited resources, Morral said the U.S. government should reconsider the prominence of marijuana in its much-publicized "war on drugs." "If our model is correct, to a certain extent we are diverting resources away from hard drug problems," he said. "Spending money on marijuana control may not be having downstream consequences on the use of hard drugs." Researchers say predisposition to drug use has been linked to genetic factors and one's environment, including family dynamics and the availability of drugs in the neighborhood.

Justices Take On Gay-Rights Case
Lyle Denniston, Boston Globe- 12/3/2002

WASHINGTON - Gays and lesbians yesterday gained a Supreme Court hearing on their persistent decades-long campaign to gain the right to privacy and freedom from discrimination for their sexual acts. Sixteen years after denouncing homosexual conduct in a bitterly divided 5-to-4 ruling, the court agreed to hear an appeal by two gay men from Houston who are challenging a Texas law that makes it a crime for individuals of the same sex to engage in sodomy.
   Their challenge is the latest in a gay rights campaign that has made major gains in recent years. In the early 1960s, every state had laws that criminalized sodomy between consenting adults. Now, only 13 states have such laws, and four of those states define only sodomy between people of the same sex as a crime. Texas is one of those four. The others are Kansas, Missouri, and Oklahoma. Nine other states ban the practice no matter what the gender of the partners.
   When the court holds a hearing on the new case in late March or early April, the justices will consider whether laws that punish sodomy between same-sex partners as a crime violate their right to privacy or their right to be free from official discrimination. In order for the court to rule in favor of the privacy claim, it probably would have to overrule its 1986 decision in the case of Bowers v. Hardwick. In that decision, the five-justice majority ruled that homosexuals have no constitutional right to privacy that includes homosexual conduct. The late Justice Lewis F. Powell Jr., who provided the decisive vote in that ruling, said later that he probably had made a mistake. The two Houston men expressly asked the court to overturn the 1986 ruling. The court has never ruled on whether punishing same-sex couples for sodomy, while not doing so when the partners are of opposite sexes, amounts to unconstitutional discrimination.
   Last year a Texas court of appeals rejected both the privacy and equality challenges to the Texas law, saying it was fully justified as an attempt to protect morality. ''Our concern,'' the state court said, ''cannot be with cultural trends and political movements because these can have no place in our decision without usurping the role of the Legislature. While the Legislature is not infallible in its moral and ethical judgments, it alone is constitutionally empowered to decide which evils it will restrain when enacting laws for the public good.''
   The lower court upheld the convictions of John Geddes Lawrence and Tyron Garner. They had been arrested in Lawrence's apartment in 1998 after a neighbor called police and gave a false report that there was an intruder with a gun in the building. On entering Lawrence's apartment, police found the two men having sex. At the time, Lawrence was 55 and Garner was 31. They pleaded no contest to the charge of sodomy, a plea that allowed them to file an appeal challenging the law's constitutionality. Each was fined $200. Their appeal succeeded in a lower Texas court, but was rejected by the appeals court, which reinstated their convictions. The gay men's appeal is supported by the American Civil Liberties Union and several gay rights groups. Supporting Texas in the case is the Pro-Family Law Center, which argues that the law is supported not only by moral considerations, but also by health-policy concerns. The justices may decide the case by early next summer.

Michigan's HMOs Make Money in '02
Detroit Free Press, 12/3/2002

Michigan's managed-care health plans improved during the three months ending Sept. 30, and only three of the 27 reported HMOs losses for the first nine months of the year. As a group, the 27 HMOs earned $94.5 million for the nine months, according to unaudited financial statements filed with the Office of Financial and Insurance Services, which regulates health insurers. Data for Ultimed HMO of Michigan had not been posted on the service's Web site as of late Monday. For the same nine months a year ago 28 HMOs reported a collective loss of $28.2 million. As of the end of June this year, 28 HMOs reported net income of $39.2 million.
   Frank Fitzgerald, financial and insurance commissioner, said he had not seen a detailed analysis of the most recent financial reports, but they generally indicated "the trend is continuing in a positive direction." "Clearly the financial strength is continuing to improve, taking the state as a whole," Fitzgerald said.
   Despite the better overall performance, 15 HMOs reported lower net income than at the same time a year ago. For example, M-Care Inc. reported a $4.6-million surplus at the end of September, but that was $5.8 million less than at the same time a year ago. Cape Health Plan went from a $2.2-million surplus to an $880,000 loss in the most recent nine months.
   Community Choice Michigan continued to lose money, reporting a negative net income of slightly more than $3 million for the nine months. The Okemos-based Medicaid health plan had lost $2.3 million at the end of six months. Bloomfield Hills-based Molina Healthcare of Michigan lost $179,281 and Procare Health Plan Inc. of Detroit lost $135,450 in the first nine months.
   Detroit-based OmniCare continued on track through its court-approved rehabilitation. The largely Medicaid HMO reported net income of $33.7 million, a significant improvement on its $1.7-million surplus at the end of six months. By this time last year, OmniCare had lost more than $17 million. Complete financial results of all Michigan's HMOs can be found at the state agency's Web site, www.michigan.gov/ofis. Go to Consumer Services.

To Prevent Sexual Abuse, Abusers Step Forward
Linda Villarosa, New York Times- 12/3/2002

"I am a recovering child sexual abuser," said the lanky 71-year-old man. "For several years in the early 90's, I abused three of my grand-daughters." As he spoke, the noisy room was stunned into silence. The man and his wife, from rural Vermont, were speaking in front of a group of about 100 teachers in Burlington. "After each of the incidents, I felt guilty and hated myself," said the man, who also told of being sexually abused as a boy. "I vowed to stop, but I didn't. My stepdaughter confronting me is what finally stopped me."
   The man and his wife, who do not use their real names when addressing groups in the workshops and asked that their names not be used to spare their grandchildren additional pain, are part of an unusual program sponsored by Stop It Now, a sexual abuse prevention group based in Haydenville, Mass. Instead of focusing exclusively on the victims of abuse, these programs also let abusers talk about what they did.
   The goal is not only to allow abusers to educate the public about sexual abuse, but also to rally adults -- friends, family, neighbors, teachers, professionals and the abusers themselves -- to act before abuse ever occurs. Never before, say those in the field, has a prevention program directly asked abusers to step forward. And rarely, they say, has a program asked the public at large to confront suspicious behavior in adults.
   For the past two decades, nearly all sexual abuse prevention programs have focused on children, rather than the molesters, experts say. Children, abused at a rate of 500,000 a year in this country, have been taught the difference between good touch and bad touch, Instructed to say "no" if they are being violated and encouraged to get help. But the crisis in the Roman Catholic Church again highlights how difficult it is for children to come forward and confront the adults who are harming them.
   "This approach marks a huge shift in the field," said Dr. Keith Kaufman, a professor and chairman of the department of psychology at Portland State University in Oregon. Dr. Kaufman is the president of the Association for the Treatment of Sexual Abusers, a nonprofit organization based in Beaverton, Ore., that two years ago began endorsing a prevention model that focuses on offenders. "We have had a 20-year history of a singular approach to prevention with a focus on relying on kids to protect themselves from adults," Dr. Kaufman said. "This doesn't even make sense logically. Why do we think it's right to give children the huge responsibility of protecting themselves from sexual offenders?"
   For the first time, the Centers for Disease Control and Prevention this fall has financed two state-based programs that focus on preventing adults from abusing children. Prevent Child Abuse Georgia, an Atlanta-based, non-profit organization, has just begun a three-year pilot program that will use a public awareness campaign to identify and educate potential sexual offenders. In New England, Massachusetts Citizens for Children has created a school-based curriculum that will include teaching teenagers how to understand and identify inappropriate sexual feelings they have toward younger children.
   These projects and others join the work of Stop It Now, which pioneered prevention programs like these in the early 1990's. In 1995, the organization instituted a campaign in Vermont, using print, billboard and public service announcements. For instance, one television public service announcement featured the voice of a mother who had sought treatment for her 10-year-old son after she saw him put his hands down the pants of a 5-year-old girl. Another, using actors to depict a real case, described how a sister confronted her brother, suspecting that he was having sexual feelings toward their young niece. People were encouraged to call a toll-free number for information, treatment referrals or simply to talk. Comparing knowledge before and four years after the campaign, a Vermont telephone survey revealed a 40 percent increase in the number of people who could define sexual abuse, a 10 percent increase in respondents who could identify at least one warning sign and a 6 percent increase in the number who conceded that abusers were likely to live in their neighborhoods. Since then, Stop It Now has created similar programs in Philadelphia, England and Ireland and will begin a project in seven counties in Minnesota next year.
   Stop It Now is modeled after other public health campaigns, like the one created by Mothers Against Drunk Driving. "I thought about the shift we have seen in behaviors like drunk driving and smoking," said Fran Henry, the founder and director of Stop It Now. "People are willing to confront and challenge people from getting behind the wheel, because they've heard the message that "Friends don't let friends drive drunk,' " Ms. Henry said. "That clicked for me. Why couldn't we use those principles to both understand child sexual abuse and get adults to hold other adults accountable for their inappropriate behavior?"
   Ms. Henry, 53, also brought her personal experiences to her work. She was sexually abused by her father from age 12 to 16. "I tried to get my father to stop, but wasn't able to until I was older," she said. "As a young teenager, I could never disclose what was going on if I knew my father would go to jail. My goal to was to try and protect kids, by getting adults to take action, so that what happened to me never happens to another child."
   Among the most controversial aspects of Stop It Now's work have been the two dozen workshops that spotlight offenders like the Vermont grandfather. Nick, a 58-year-old cook at a New England university, has taken part in six or seven Stop It Now workshops. He was arrested 13 years ago, after admitting that he had molested three of his daughters and two of their childhood friends. He spent a year in prison and many more in treatment. Nick, who uses only his first name in workshops and agreed to be interviewed on the condition that his surname be withheld, said he spoke to groups because it was his responsibility to participate in the process that identifies and stops other perpetrators of inappropriate sexual behavior." "If I can help offenders see that what they are doing is wrong, and that there is a way to change, then I have served as a good example," Nick said.
   Some find this approach ineffective, taking attention and resources away from those who have been abused and directing it toward those who have preyed children. Stop It Now has even been accused of being an "amnesty program" for offenders.
   Judy Little, executive director of Voices in Action, a nonprofit organization for victims of child sexual abuse outside Cincinnati , says that though offenders have a responsibility to prevent abuse, listening to them is difficult. "The professional and humanitarian in me believes that if we are ever to stop this cycle, we have to help perpetrators heal and allow those that are healed to take part in prevention," said Ms. Little, who was abused as a child: "But part of me is still hurting inside from the abuse that I suffered, so I don't care what they have to say. I don't want to hear the empty excuses for their behavior."
   Results from the Stop It Now telephone survey in Vermont found that only 66 percent of respondents would take direct action if they suspected abuse, and the number dropped to 43 percent if the abuser was someone they knew. Stop It Now's help lines in Vermont and Philadelphia have taken 2,009 calls since 1995, 352 from people who identified themselves as abusers or someone at risk for abusing. Another 1,299 calls were from adults who knew an abuser or someone at risk for abusing. Because many state laws require all professionals to report child sexual abuse to the authorities, callers generally do not leave their names. But the professionals can give them referrals and other information anonymously.
   It is unclear how many abusers or family members have called to seek treatment, but most experts guess the number is few. "Stop It Now is pushing the envelope, but it is still naive to believe that offenders and their families will come forward in droves, given the denial around sexual abuse," said Gail Burns-Smith, executive director of Connecticut Sexual Assault Crisis Services in East Hartford, and chairwoman of the board of the National Alliance to End Sexual Violence. "Offenders have distorted thinking about the crimes they are committing against someone," she continued. "They don't see that they are doing harm to their victims. I'd say that, at best, this approach is only a hopeful solution."
   Even Nick doubts that hearing a recovering offender speak would have stopped him from abusing or compelled him to stop. "I'm not sure if hearing someone like myself would have changed my behavior," Nick said. "On one level I knew what I was doing was absolutely unacceptable. But while I was perpetrating, I disassociated myself. I was in denial." "Looking back," he added, "it doesn't make sense how my daughters had become sexual objects to me. It was a force I don't fully understand. What I do know is that even as I was offending, I didn't want to be doing what I was doing."
   Wayne Bowers of Lansing, Mich., who has twice been convicted of "indecent liberties with a child" for sexually abusing boys on the baseball team he coached, said that perpetrator-prevention might have helped him change. "While I was offending I was out of control, but I was also sick and tired and looking for help," said Mr. Bowers, 57, who is the director of the Sex Abuse Treatment Alliance, an advocacy and education group. "I was scared to death and wanted to talk to someone, but I had no idea who," Mr. Bowers said. "If there had been a help line, I would have called it. I served my time, I got treatment and I haven't victimized anyone for 20 years. I have an attraction to adolescent boys, and there isn't any way that I can totally eliminate those feelings. But I've found a way to keep myself in control. There is hope."

Patch Raises New Hope For Beating Depression
Mary Duffy, New York Times- 12/3/2002

It was the first type of antidepressant, and for many people the monamine oxidase, or MAO, inhibitor remains the best hope for relief from major depression. The trouble is that the side effects can be so serious that MAO inhibitors are rarely prescribed. When taken with certain foods, for example, they may bring on sudden and severe hypertension. The problems, however, may soon be resolved.
   A study reported in November in The American Journal of Psychiatry suggests that by administering the MAO inhibitor selegiline in patch form, patients can receive the antidepressant benefits of the drug without the usual side effects. In research conducted at six sites, 42 percent of the subjects treated with the patch recovered from major depression within six weeks, and many showed great im-provement much sooner. In the study, neither subjects nor researchers knew who had received the dummy medication.
   One subject, requesting anonymity, told how his mood changed after a few weeks on the patch, saying: "It was like a switch had gone on. Before I had the patch, I could-n't function. Suddenly, I had a dramatic change in outlook. I could look forward to things."
   Monamine oxidase is an enzyme found in the brain and in the digestive system. By inhibiting MAO in the brain, the antidepressant is believed to give patients a better supply of neurotransmitters to fight the symptoms of depression. Taken orally, however, the medication also blocks MAO in the digestive system, and that interferes with the detoxification of tyramine, a harm-ful byproduct of many aged foods.
   Patients receiving MAO inhibitors are instructed to follow a tyramine-restrictive diet, which means no aged cheeses, no red wine, no soy sauce, no fermented foods and little or no alcohol. Eating tyramine-rich food while taking a MAO inhibitor can cause sudden and severe hypertension. Delivering selegiline through the skin, however, changes the way the medication is absorbed. Rather than first being filtered through the intestines and liver, in patch form, the drug is aimed at the central nervous system.
   "With this study we've demonstrated a way of getting an MAO inhibitor to the brain without interfering with the MAO in the digestive system," said the study's lead author, Dr. Alexander Bodkin of the clinical psychopharmacology research program of McLean Hospital in Belmont, Mass. The study was supported by the developers of the selegiline patch, Somerset Pharmaceuticals of Tampa, Fla. While subjects in this study were instructed to follow a tyramine-restricted diet, in subsequent studies they were not.
   Dr. Beverly McCabe, a professor of dietetics and nutrition at the University of Arkansas for Medical Sciences and a co-author of the "Handbook of Food and Drug Interaction," to be published in January, believes this form of drug delivery offers great promise. "I would think the risk of a tyramine reaction would be very low with transdermal selegiline," Dr. McCabe said. "The drug would absorbed into the bloodstream more evenly, which would also be beneficial."
   Dr. Frederic Quitkin, director of the depression evaluation service at the New York State Psychiatric Institute in Manhattan, said, "MAO inhibitors are really great drugs: Complicated to use, but extremely effective." As for the selegiline patch, he said, the research is encouraging. But he cautioned, "It will require further study to see: how effective it is."
   Another notable finding in the study of 177 patients was the 94 percent compliance rate for those on the selegiline patch. That is significant, said Dr. Bodkin, because compliance rates with oral antidepressants are typically much lower. One side effect, in 36 percent of subjects, was a reaction, like redness or irritation, at the site of the patch. For most patients, Dr. Bodkin said, the irritation, is minor compared with the side effects of most antidepressants.

What's Normal? A Look At Asperger Syndrome
David Corcoran, new York Times- 12/3/2002

"American Normal: The Hidden World of Asperger Syndrome," by Lawrence Osborne. Copernicus Books, $27.50.
It was an exciting moment for me -- and, I imagine, for other parents of children with the baffling neurological disorder called Asperger syndrome- - when The New York Times Magazine published Lawrence Osborne's "Little Professor Syndrome" in June 2000. The title may have been condescending, but the article itself was terrific, perhaps the best yet about Asperger's in a mainstream publication: a 9,500-word exploration, in remarkably vivid and sympathetic language, of a world that few readers had visited. So it was doubly exciting when Mr. Osborne, a widely published health and science journalist, expanded the article into a book, "American Normal," published last month.
   Asperger's, as most readers probably still need to be told, is a lifelong disorder of unknown origin that usually shows up around 18 months to 3 years. Generally thought to be a form of autism, it is characterized by normal or above-normal intelligence, social awkwardness, verbal rigidity and, most conspicuously, a fixation with an obscure topic that can be learned by rote.
   People with Asperger's have a hard time relating to other people. But they can and do go on for hours about their obsession -- Civil War battles, lighting fixtures, members of Congress, train engines (hence, "little professors"). The syndrome has no known cure. But growing awareness of it, coupled with the federal law that requires schools to provide appropriate services to students with disabilities, means that many more children than in the past are receiving needed attention and can hope to grow into happy and productive adults.
   Still, what Asperger's awareness has lacked is a wide-ranging book by a writer with journalistic and literary credentials -- a book that could do for Asperger's what Oliver Sacks's "Man Who Mistook His Wife for a Hat" did for other obscure brain disorders. But those of us who were hoping that "American Normal" would be that book are in for a severe disappointment.
   It takes the form of a transcontinental odyssey in which Mr. Osborne drops in on children with Asperger's and adults who are too old to have had it diagnosed in childhood but who clearly show its symptoms. (Some are parents of Asperger's children, suggesting that the condition may run in families.)
   He is an acute observer, and his descriptions are penetrating and tinged with empathetic humor. Nicky, a 9-year-old in Adelanto, Calif., who writes tiny poems in the shape of diamonds and has already scored in the 99th percentile on an SAT, has a mind that is "disturbingly hyperfactual and blithely associative."
   A. J., whose obsession is vacuum cleaners, "loved the promotional video that came with the new Phantom model and watched it over and over, while rocking back and forth." When his grandmother disciplines him by telling him he won't be able to touch the new vacuum, "a sullen look of castigated impotence would suddenly come over his face."
   But when Mr. Osborne leaves the company of people with Asperger's, the book runs seriously off track. Much of it is devoted to long, tangential and unrewarding meditations on the American psychiatric establishment, the horrors of highway sprawl and the possibility that various figures -- Thomas Jefferson, the Canadian pi-anist Glenn Gould -- may have had Asperger's. Mr. Osborne himself suspects that he may have undiagnosed Asperger's, and he returns at tiresome length to his obsession with the "Iron Chef" television program and his insistence do staying in Red Roof Inns.
   His larger point, and the meaning of the title "American Normal," is that Asperger syndrome may be less a disorder than a societal and psychiatric construct -- a condition that he concedes is real, but one whose diagnostic criteria are "so complicated and so contradictory and so blurred around the edges as to sometimes stretch credulity." The implication is that society's obsession with "normality" has led it to diagnose anything abnormal as an illness, one that needs to be treated with expensive drugs and psychotherapy.
   It's a familiar indictment. (The introduction approvingly quotes Dr. Mel Levine, a pediatrician at the University of North Carolina, as saying, "We're pathologizing all human behavior, and in so doing we're creating an institutionalized nightmare -- a truly mad system in which everyone is `sick.' ") But Asperger's is an odd candidate, because few experts believe that drugs and psychotherapy can do anything more than relieve some of its side afflictions like depression and attention deficit disorder.
   In one of his digressions, Mr. Osborne takes us to a Malaysian tribe, some of whose members have an exaggerated reflex called latah, which causes them to go into a trance when startled and behave in ways that would embarrass them if they knew what they were doing -- cursing, taking off their clothes, singing bawdy songs. Yet in the tribal culture, such people are treated with affectionate amusement. By contrast, Mr. Osborne says, Americans with Asperger's are viewed as having a "disorder" that needs "curing." What if "around a core biological illness," he asks, "a large super-structure of behaviors and moods had been created by the society itself?"
   But the difference between latah and Asperger's is plain from Mr. Osborne's descriptions of the two syndromes. One is limited to special circumstances, and it does not disable its sufferers; the other is pervasive, meaning that it invades nearly every aspect of a patient's life. This book trivializes its subject by making it a vehicle for a diatribe against psychiatry and the larger ills of society. In the end, it turns out to be less about Asperger syndrome than about its author. The subject is not as fascinating as he seems to think it is.

Bipolar Illness: Slowing the Roller Coaster
Benedict Carey, Los Angeles Times- 12/5/2002

The ideas come in a swarm, and they can be good ones: Move to Prague and teach English. Study jazz piano in the early-morning hours. Start a dot-com; hike the Appalacian Trail; write an opera. "I wanted to save people" said Agnes Zsigovics, 28, a student in social work living near San Diego, who in her early 20s made plans to teach children living in the mountains of Venezuela -- only to ditch the idea at the last minute and fly to Montreal to teach Spanish. "I just had way, way too many projects in my head. I can tell you this: People with bipolar disorder have the most interesting lives."
   They can, also have, dangerous lives. Bipolar disorder is another name for manic depression, an incurable, lifelong mental condition in which people zigzag from these effusive emotional highs to paralyzing periods of despair, often accompanied by thoughts of suicide. Recent studies suggest that as many as 10 million Americans are afflicted with the condition to some degree -- far more than previously thought. The illness goes unnoticed or undiagnosed in many people because their manic episodes are neither dramatic nor especially destructive, psychiatrists report. The findings have prompted a wave of research into new drug and talk therapies and an increased willingness among psychiatrists to seek guidance from patients and their families. What we're learning is that patients do a lot better if they're collaborating on their own treatment" states Dr. Gary Sachs, lead investigator of a large national study that is following about 2,500 patients with bipolar disorder and comparing treatment approaches.
   Preliminary evidence from the trial, sponsored by the National Institute of Mental Health, suggests that patients are the best judge of what triggers their manias and that their family and friends are crucial allies in managing the disorder. "It's as if you're co-managing a baseball team, working together to decide which combination of drugs and therapy work best, and when," says Sachs, director of the bipolar treatment program at Massachusetts General Hospital.
   For half a century doctors have treated bipolar disorder with regular doses of lithium carbonate, a naturally occurring mineral that acts in many patients like a steady hand on the emotional tiller. Although neurologists don't yet know how bipolar disorder develops, the mood swings have been linked to tidal shifts in the levels of chemical messengers in the brain, such as serotonin, glutamate and dopamine, which help people experience emotions. Lithium appears to calm these chemical waves, and in the process has spared uncounted millions from suicidal thoughts. Actress Patty Duke, in her autobiography "Call Me Anna" which describes her battle with bipolar disorder, calls lithium her savior, a drug that rescued her from probable suicide.
   People with untreated bipolar disorder are about 30 times more likely to commit suicide than the overall population, in which 12 of 100,000 take their own lives. Even patients who receive treatment experience frequent relapses, and many will plunge into drug and alcohol abuse, or contemplate suicide, psychiatrists say. Often, the relapse can be due to the treatment itself. Researchers at the New York State Psychiatric Institute reported in June that about one of every three bipolar patients who visited psychiatrists during the 1990s received no mood-stabilizing medication. Many got only antidepressants. The problem is, while antidepressants may lift the mood of someone with bipolar disorder, they also often propel them into a manic episode and depressive rebound, accelerating their cycles and making the problem worse, researchers and patients say. For all its power to dampen mood swings, lithium also fails to prevent relapse in at least half of people with bipolar disorder, according to Dr. Mark Rapaport a psychiatric researcher at the University of California, San Diego. But in the last several years doctors have begun to experiment with a variety of anticonvulsant drugs, which appear to be effective at stabilizing mood swings, decreasing the frequency of both depression and mania, he said.
   In the federal study led by Sachs researchers have found that the suicide rate over two years is about half of what doctors would expect to see in a group of bipolar patients receiving treatment. Researchers attribute some of this improvement to the careful attention patients are getting, which likely has a soothing effect. Another possible factor is that about one in four patients is taking lamotrigine, a drug used primarily to control seizures in people with epilepsy. "This drug appears to be especially useful in preventing people from relapsing into the depressive phase," Rapaport said. In other trials, drugs such as valproic acid (Depakote) and olanzapine have also proved useful in some patients as mood stabilizers.
   Drug treatments almost always work best when combined with some form of psychotherapy, doctors said. For starters, a good therapist makes sure patients take their medication, without fail, no matter how much they may miss the power and energy of their manic episodes. "When you're on, you can feel very good," Zsigovics said. "It can be hard to give that up." Therapists also can teach patients some of the same self-control techniques that help longtime smokers and drinkers quit: Identify the situations or stresses that trigger episodes; diffuse or avoid them, if possible; and stick to stable daily work and sleep routines. Several recent studies have shown that disruptive events -- work pressure, arguments with a spouse -- are strongly linked to manic episodes in people with bipolar disorder, "I can tell you that for me being extremely rushed, or being challenged aggressively in an argument, can put me at risk" of a manic episode, said Stephen Propst, 38, of Atlanta, who operates a Web site at www.atlantamoodsupport.com for bipolar sufferers and their families. "And when you're not up to par, there are things, like social occasions, which only aggravate the illness."
   That's where close friends and family members come in. Over the last several years, David Miklowitz, a psychologist at the University of Colorado, has studied the effect of family counseling on the behavior of patients with bipolar disorder. In a 21-week course, Miklowitz teaches patients' parents and siblings how to spot the warning signs of an imminent manic episode -- the increased irritability, the big plans, the fast talking -- and manage them by dialing down tension in the home. One of the techniques is called the "three-volley rule." If a disagreement with the patient prompts an escalating series of three personal attacks, it's time to back off; change the subject if you can, or enlist the person in solving whatever the problem is," Miklowitz said. "In some ways, these techniques are similar to marital therapy for high conflict couples."
   In one recent, study involving 101 families, Miklowitz reported that bipolar patients who received mood-stabilizing drugs and family-focused treatment had a 29 percent risk of relapse over the course of a year, compared with a rate of 53 percent among patients who got medication and no family counseling. A similar study, due to be published next year, finds that a counseling program that involves the patient's family is a more powerful check on mood swings than programs that focus solely on individual therapy. Relapse rates in those who received drugs and individual counseling were 60 percent during the year, five times higher than the rate among those whose families were involved in treatment.
   Most patients say the emotional seesaw never completely stops. But new combinations of treatment are making the ride easier for many. "The difference is that without medication and social support, it's like you're standing up in the car, with nothing to hold onto," said Propst. "Once you're getting good treatment, it's like you're seated with your seat belt on."

Resilience: Thriving Despite It All
Melissa Healy, Los Angeles Times- 12/6/2002

When he was 6 years old, Rasheen Coleman's drug-addicted mother chased him around a room wielding a knife and threatening to cut off his fingers. For years, his mother regularly berated Rasheen and beat him with anything that was at hand: her purse, a broomstick, her fists. The little boy was regularly in charge of two young half-siblings, preparing their meals and supervising their play. Any lapse -- a middling report card or a brother's naughty behavior -- would bring a storm of his mother's verbal and physical wrath upon Rasheen. And then, when Rasheen was 12, his ordeal was over. His mother died of AIDS.
   By reliable estimates, more than half of kids like Rasheen would enter adulthood with festering psychological wounds of one sort or another. A victim of such severe abuse is more likely than the broader population to have fallen prey to mental illness or addiction, to have dropped out of school, relied on public aid or run afoul of the law. He or she would be far more likely to have had a string of failed relationships or jobs. Almost half, according to one study, would go on to abuse or neglect their own children.
   But somewhere at the core of Rasheen Coleman, there is a certain steel. And perhaps too, at the core of kids like him lies a more subtle alchemy: the secret to mending, and maybe even preventing, the emotional wreckage that child abuse and neglect can leave in its wake. It is a prospect that mental-health professionals increasingly hope to mine.
   Now a 25-year-old graduate student at Texas A&M, Coleman proclaims "an abundance of hope." He lives a life surrounded by friends, directed by ambitions and disciplined by the experience of having faced crushing adversity and beaten the odds, all at a tender age. Coleman struggles -- mightily and daily. But most days, optimism and discipline just seem to trump the fear, anger and self-doubt of his childhood. He is shy, but pushes himself toward a career in politics. He likes to party and have fun, but won't allow himself so much as a cigar for fear of addiction. He wants to forgive the woman who turned his childhood into a nightmare, but also wants to forget her and move on. "I'm more than a conqueror," says Coleman in a voice that conveys more conviction than boast. "Whatever I face, I know I'll be able to overcome it. I don't let things get me down."
   For those who study the long-term effects of child abuse and neglect, survivors like Coleman are models of resilience, and, increasingly, objects of intense scrutiny. Early in his adulthood, Coleman appears to have escaped the most typical effects of a childhood marked by severe abuse, including depression, criminality, academic failure and substance abuse. According to the Department of Health and Human Services, 984,000 children were victims of maltreatment in 1998, the latest year for which figures were available. More than half suffered neglect, while almost 1 in 4 were physically abused. Nearly 12% were sexually abused.
   The mistreatment of children is as old as parenthood itself, and the study of child abuse and neglect is a venerable academic field. But a recent event -- the terrorist attacks of Sept. 11, 2001 -- has brought new focus and research funds to the community. After thousands of children were exposed directly to the horror of those attacks -- and millions more through public media -- government officials scrambled for insights into the causes, effects and treatment of childhood trauma. Those who study and treat victims of child abuse were among the first to step forward with treatment programs and ideas for further study.
   It was not their first foray into subjects making news. During the 1980s and '90s, many in the child-abuse field turned to the study of children traumatized by gang- and drug-related violence in their communities. Studying ever-broader populations of children, says Joy Osofsky, a leading thinker in the field, has helped the field mature quickly. And the new focus on "protective factors" -- or resilience -- is a result of that, she adds. "With more understanding about how trauma impacts children, we've learned more about children who experience trauma differently," says Osofsky, vice president of the organization Zero to Three, and a psychologist at Louisiana State University. "And we've seen that somehow, with various resources and circumstances, some children are able to weather it and move on." While the research lags behind that observation, the intriguing treatment implications of "protective factors" are sparking more interest than ever, she adds.
   Throughout the mental-health profession, the new emphasis on resilience serves two purposes. First, it is a hopeful reminder from social scientists that the abused child does not always face an immutable sentence of doom: They are asserting that factors such as child abuse -- or low birth weight or a family history of mental illness -- stack the probabilistic deck against a kid. While they may warn of "increased risk," they are not predicting his guaranteed failure. Some kids, they acknowledge, emerge perfectly fine. Second, social scientists hope that if they can distill the qualities of resilience in some children, they can use these lessons in the treatment of all abused or neglected children.
   But if the idea is simple, it is a vastly more complex challenge to tease out and treat the effects of violence and indifference on a child. The virulence and duration of a child's exposure to abuse matter -- and vary widely from one case to another. And so, apparently, does the nature of the mistreatment. Neglect, while frequently lumped with abuse, may leave fewer physical scars but deeper psychological hurt than some hitting. It was long believed that a youngster would not be harmed by witnessing the abuse of another in his home. Now, researchers suspect that the resulting fear is psychologically as corrosive as direct abuse of the child. And while sexual abuse may still be the most shocking form of mistreatment, many clinicians are beginning to believe that emotional abuse -- constant criticism and berating -- wreaks the greatest damage in the long term.
   Beyond that, the temperament a child starts life with matters greatly -- whether she is irritable or easygoing will affect not only how well she copes with adversity, but how a parent will respond to her and whether the two will form an early bond. And along the path of her childhood, the serendipitous appearance of an adult "buffer" -- a stepparent, teacher or coach -- can spell a world of difference in the life of an abused or neglected child. "There is no magic pill," says L. Alan Sroufe, a psychologist at the University of Minnesota's Institute of Child Development. Resilience, Sroufe notes, "is not just something you have or don't have; it's a developmental construction."
   In other words, resilience does not simply happen to some kids and not to others. It evolves in some kids, given the right circumstances, and it can atrophy in those who get no emotional support from inside or outside their family, says Sroufe. "There are no good seeds or bad seeds. There's virtually no child who, with enough help, doesn't do OK, and no child who, if enough is going against them, doesn't struggle." Steven Wolin, a Washington D.C., psychiatrist, calls resilience a potential which is present in every child. "It's like having biceps -- muscles with potential. How they develop depends on how much and how you use them."

Removed from home
Although his youth was punctuated by terrible pain and loss, some circumstances did smile on Rasheen Coleman, and the little boy's sweet nature seemed to help draw sympathetic adults to him. When he was 10, the state of Texas removed Coleman and his half-siblings from his mother's home and, after bouncing briefly from orphanage to foster family, they landed in Omaha, Neb., with his aunt, a hard-working mother of three. There, he became involved in the South Omaha Boys Club (now the Boys & Girls Club), and met a series of staff counselors whose attention, he says, made him feel special and built his self-confidence. If he did not show up at the club when he was expected, a counselor named Ruth Hamlin would venture into the public housing complex he lived in with his aunt and collect him -- a gesture of commitment to him at which Coleman still marvels more than a decade later.
   Although he was not athletic ("I realized later that fast-moving things around me made me feel nervous," he recounts now), counselors drew him into community service projects, which had a profound effect on him. "I felt like, 'I can do this,' " says Coleman. "This shy, withdrawn person who really didn't feel like I wanted to live: I had this sense of usefulness, a sense of worth, a sense that I belonged."
   He attended Creighton Preparatory High School, a Catholic school where, he remembers, a teacher named Tom Hoover once told him, "Rasheen, you're a leader -- a quiet leader, but sometimes, that's just what's needed." Coleman went on to be named the Boys & Girls Club of America's Youth of the Year in 1997 -- an honor that involved speaking often and publicly about his painful past. The recognition also landed him in the Oval Office for a brief chat with President Bill Clinton. In 2001, Coleman graduated from Morehouse College in Atlanta, one of the nation's leading traditionally black colleges.
   But lucky breaks late in adolescence clearly are not enough. If there is one point on which most researchers agree, it is that the cornerstone of a child's resilience is his first loving bond to an adult. "The best resilience predictor for a child is a caring relationship with one adult, hopefully a parent," says Patricia Van Horn of UC San Francisco's Child Trauma Research Project. "The more relations like that, the better. But children who have at least one do better than those who don't."
   The UCSF project, housed at San Francisco General Hospital, traditionally has treated children who have watched as their primary caregiver, usually the mother, were abused by a partner. In many cases, the child herself also was abused or neglected, compounding the trauma. In an effort to fortify the traumatized child, Van Horn and her colleagues first must try to repair a relationship between that child and her mother (or whoever cares for her), which has been roiled by the domestic violence. The battered parent and child often see each other as reminders of the traumatic event, which disrupts communication, trust and affection. If the child is to lay down the first building blocks of healthy relationships later, the tears in the fabric of this first relationship must be mended.
   In the literature of child development, the first attachment a baby makes -- most often, though not necessarily, with her mother -- forms the basis and shapes the terms of most all future relationships. If this first give-and-take is a good partnership, a child learns about how to get his needs fulfilled and how to control his impulses. He will build the capacity to see adults as reliable and trustworthy, and so, even if the first relationship disappears or disintegrates, he should be able to reach out positively for comfort and support if another adult steps forward.
   The pivotal importance of that first bond is underscored by the work of Sroufe and his research partner Byron Egeland, both at the University of Minnesota's Institute of Development. Twenty-six years ago, the two started tracking 267 children, all from families with low income and education, at birth. From family members, teachers and the children, the research team took periodic psychological soundings, including a battery of visits and observations in the first three years.
   Sroufe and Egeland concluded that 15% of their research subjects had been abused or neglected. Among those infants growing up with a "psychologically unavailable" caregiver (children who also were, in some cases, abused or neglected), not one was deemed to have developed a "secure attachment" to that caregiver at the ages of 12 months and 18 months. By the age of 17, only four of the mistreated kids Egeland and Sroufe were following were judged to be completely free of symptoms that amounted to mental illness. In all four cases, a firm bond with a parent had been recorded at an early age.
   Egeland surmises that this early experience of trust probably makes a difference at a critical juncture: When a caring adult reaches out to support a mistreated child later in his school-age years, the child who had some early experience of an adult as reliable and trustworthy was able, socially and psychologically, to grab the lifeline. Children without that foundation may have rebuffed or failed to recognize such overtures, and never found what Coleman said he found in the staff of the Boys & Girls Club: "a second home and a second family."

A respite with 'Big Ma'
Indeed, in Coleman's case, the early signs were promising, as well. When Coleman was 6 months old, his drug-addicted mother willingly handed him over to the stern, God-fearing matriarch of her family, whom he came to know and love as "Big Ma." For the next five years, Rasheen has happy memories of a childhood in Bertha Moore's prodigious shadow. Growing up in Mobile, Ala., he remembers singing in the church choir, sitting with the adults right behind his great-grandmother. He remembers being the one to carry her cookies to all the church functions. She was strict, he says, but fair and loving. "The person I am today was because of her."
   When Rasheen was 6, he heard a banging at the door and a hollering he knew was his mother's voice. She snatched the boy up from in front of his cartoon and drove with him and a half-sister and brother he had never met from Alabama to Dallas. A stepfather passed briefly through his life, bringing a measure of protection and companionship. But he abandoned Rasheen, under a rain of his mother's blows as well.
   This four-year ordeal of neglect, abuse and loss has not been without consequences for Coleman. He acknowledges that he is extremely reserved about his emotions and has found it hard to sustain a close romantic relationship with a woman -- problems that UCSF's Van Horn says are a classic fallout from abuse involving a parent. "Just relating to women, I find it very difficult. Not having that love and affection from my mom or my dad has been difficult," says Coleman now, who says he draws his greatest strength from his Pentecostal Christian faith. "I just have to grow and mature. I won't use it as an excuse.... I have to decide I want to be a great husband, a great father."
   Now finishing his master's at the George Bush School of Government and Public Service, Coleman hopes to marry a woman who is his mother's opposite -- and his own complement. Not explosive. But also not too shy, like he is himself. And would he ever hit or berate the wife and two children (first a boy, then a girl) that are the family of his dreams? Here, Coleman relies on the happy confluence of the many factors that have made his life so far a triumph against bad odds. He has faced the pain and loss, often and openly. And Coleman acquired a gift for empathy. "I don't think I would ever do to my kids, or to my wife, what my mother did to me," says Coleman quietly. "I just know how it felt -- and I would never want anyone to feel like that, especially my kids."

Rape Victims Have Shoulder to Lean On
Jo Collins Mathis, Ann Arbor News- 12/8/2002

Washtenaw County professionals have always been ready and willing to help victims of sexual assault. But until recently, these law enforcement officers, detectives, nurses and advocates often didn't know each other and weren't clear on who was doing what for whom. Victims sometimes waited several hours in the emergency room to be examined by someone who may or may not have been trained to handle sexual assault cases. Data collection was inconsistent and prosecutors found it difficult to get hospital residents to testify in court if they'd moved out of state by then.
   That's all changed now that the Washtenaw County Coalition on Gender Violence and Safety has formed the Washtenaw County Sexual Assault Response Team, or SART program, which provides round-the-clock coordinated services to victims of sexual assault.
"The fact that we have streamlined services available to survivors so they don't have to do everything over and over again and get dropped through the cracks is amazing," said Kent Baumkel, a coordinator of the coalition. "The coalition works to pull organizations together that provide different pieces of assistance and then coordinate those services so they are streamlined and improved."
   Early one September morning while she was sleeping, a 23-year-old Ypsilanti woman was sexually assaulted by an acquaintance of one of her roommates. Nearly in shock, she ran downstairs and woke her roommate, who called 911. The Ypsilanti police arrived quickly and arrested the suspect. A female officer talked with the woman, who then went to the hospital with her roommate. Once there, the SART nurse and advocate on call were contacted by the hospital.
   "They came right away, and they were so helpful," recalled the woman, who asked not to be identified by name. "They came in and talked to me, gave me some information, some numbers I could call if I needed to talk to anyone at anytime." She said the examination room was private and the nurse made her feel as comfortable as possible, while taking the time to get all pertinent information. The woman went to the Sexual Assault Crisis Center a few days later, and was paired with an advocate, who has counseled her since then and will be with her in the courtroom when the case comes to trial in February.
   There is no way of knowing how many sexual assaults occur in Washtenaw County in an average year because many are not reported, sexual assault support groups say. But in 2001, the Washtenaw County prosecutors charged 101 cases of criminal sexual conduct. So far this year, 93 people have been charged with CSC. And since SART's start on Aug. 1, 30 women have been helped at St. Joseph Mercy Hospital by its SART team, and another dozen at the University of Michigan.
   Victims have reported feeling cared for and supported, said Sheila Briggs, coordinator of St. Joe's Sexual Assault Nurse Examiner program, or SANE. "All the feedback from clients has been very positive," said Briggs, who has been present for all 30 exams there. "They think it's a nicer atmosphere than being stuck in the chaos of the emergency department. They get one-on-one care. They get one nurse doing the whole exam versus a doctor, a resident, a nurse, several people coming in and out of the room."
   Victims have been helped by advocates from local crisis centers for years, said Therese Doud, advocacy services coordinator for the Sexual Assault Crisis Center of Washtenaw County. But sometimes, the hospitals didn't alert them, so service was sporadic. "We know the important first step is the kind of contact the rape victim has with hospital personnel and an advocate," she said. "That can really set the tone for what her recovery's going to look like. If she gets a sense that she's not believed; if she feels she's pooh-poohed, or this isn't very important, that can set the stage for self-doubt." The right support gives victims hope that they will regain their lives, and connects with a continuum of services available to them, including group and individual counseling, Doud said.
   All 11 law enforcement agencies in the county are required to contact the 24/7 SART Line when a sexual assault is reported. If a victim goes directly to the hospital, hospital personnel provide support, collect information, offer SART Program services, contact law enforcement and call the 24/7 SART Line to activate the team.
   Dan Oates, Ann Arbor's Chief of Police, made changes in the detective's bureau so that now virtually all sexual assault. cases are assigned to one of several detectives specifically trained to handle sexual assault cases. Before SART the sexual assault cases were assigned on a rotation basis to the detective on duty. "There's such unique sensitivities to sexual assault cases; you want people who are specialists to handle them," said Oates. "(The SART approach) is exactly what you want to do in policing, in responding to a need in the community. It fits exactly."
   Mark Kneisel, who prosecuted sexual assault cases for two years in Washtenaw County and is a coalition co-chair, expects the new system will lead to an increase in convictions. "I know that it has in other communities," he said, noting that none of the SART cases have come to trial yet. "There's better evidence collected sooner, and that should certainly turn into a more reliable result in the courts. We want the conviction rates to go up, but, equally if not more importantly, we want the victim to be responded to and respected."
   According to Susan Kheder, program director for Women's Health Services at St. Joseph Mercy Health System, a key component of the program is the presence of nurses who've received more than 40 hours of classroom training and clinical skill development in performing these exams, as well as other issues involving sexual assault, including legal implications, psycho-socio-dynamics and prosecution-related issues. Nurse examiners now have forensic training that equips them to go to court to testify as part of their jobs. If the woman doesn't have insurance that takes care of the services, which is typically covered under emergency room care, St. Joe's has a grant program that will offset the cost.
   Lisa Scheiman, certified nurse midwife at U-M and director of the SANE program there, explained that the coordination of the SART team better meets the needs of the victims. "Before, the midwives did the exams and we did a good job," she said. "But now with everyone working together as a team, it really meets the needs of the women the best."
   A rape victim should get to the hospital within 72 hours in order for the examination to be effective for collecting evidence. But if for some reason she waits longer than that, the SART team can still be activated and the victim can still see a SANE nurse if there is a visible injury that could be recorded with sophisticated photography equipment.
   The Ypsilanti woman who was assaulted in September has learned five of her friends have been raped or sexually assaulted, and she was dismayed to learn that none of them reported it. Now they regret it because there has been no closure, she said. The woman said she has no regrets about reporting the crime and going to the hospital, which activated the SART team that continues to help her. "It's a shame that a lot of women don't report the assaults that have been brought upon them," she said. "I very pleased because - although I have to do a lot of waiting - at least I know I'm OK, relatively speaking. I know this person is in jail and will be there until trial." "I just want justice to prevail. It's a crime and I just want to stand up and say, `Hey you can do something about it.'"

New Vaccine Clause Angers Parents of Autistic Children
Susan Warner, Washington Post- 12/9/2002

Thomas Brinker loves to sing and play with string. He watches ABC News anchor Peter Jennings on television every night and shouts: "Tickle Peter Jennings." He's 8 now, but his attention span is short and his temper flares easily. Thomas has autism, a condition his parents believe was caused by a simple childhood immunization. "We're waiting for his first normal moment," said his mother, Donna Brinker of Glen Mills, Pa.
   It was Donna Brinker's temper that flared when she learned that Congress had quietly restricted her right to sue Eli Lilly and Co. and other manufacturers of Thimerosal, the mercury-based vaccine preservative she believes caused her son's condition. The change came in two paragraphs tacked onto the massive Homeland Security Act just days before Congress approved the legislation in November. The Brinkers are among 800 families in more than a dozen states that have filed similar cases seeking compensation for the costs of their children's autism. Under the new law, signed by President Bush Nov. 25, the parents are required to file claims with a special administrative court under the National Vaccine Injury Compensation Program before they can take their cases to civil court.
   The changes could sharply reduce parents' chances of prevailing in civil courts, where damage awards normally could be much higher than those in the "vaccine court." The federal program covers claims for medical and education expenses, but damages for pain, suffering and death are limited to $250,000. Lawyers for the plaintiffs say their awards would likely be higher if they could first take their cases to state courts, where civil juries are known to award millions of dollars in medical injury cases. Meanwhile, the Department of Justice has filed a request to restrict the use of information gathered in vaccine court proceedings in subsequent civil court cases, another potential obstacle for the plaintiffs.   "I felt betrayed," Brinker said of the new legislation. "I believe in protecting our homeland, but it petrifies me to think that our nation would protect any industry at the expense of our children." Penny Starr-Ashton, of Drexel Hill, Pa., whose autistic 6-year-old daughter, Maddie, is another plaintiff in a class-action lawsuit filed in Pennsylvania in July, said it is particularly painful to have the provision wrapped in the flag. "Who doesn't want a safer country?" she asked. "But who's going to protect me? Who's going to protect my child?
   The National Institute of Child Health and Human Development estimates that between 1 in 500 and 1 in 1,000 children is diagnosed with autism in the United States each year. Initial studies in the 1960s found four to five cases of autism in every 10,000 people, although the institute cautions that some of the increase could be due to changes in reporting and diagnosing the disease. A study by the University of California at Davis found that a third of California parents of autistic children diagnosed in the mid-1990s blame vaccines for their children's illnesses.
   Congress created the National Vaccine Injury Compensation Program in 1986 to address growing concerns about vaccine safety. Claims are filed with the Department of Health and Human Services through the U.S. Court of Federal Claims. The program has paid out 1,775 claims totaling $1.4 billion and is funded by a 75-cent surcharge on every child vaccination.
   Brinker said parents of children with signs of mercury poisoning can spend up to $20,000 a year out of pocket. Thomas is undergoing chelation therapy to draw metals out of his body and is on a strict diet. His parents take him to a specialist in Louisiana for treatment, and his mother travels to Mexico to get drugs that are not approved in the United States. Beyond today's expenses, Brinker worries about supporting Thomas in the long term. "The mercury preservative has deprived Thomas of having a normal life," she said. "That our nation would protect such a killer is beyond comprehension."
   Aside from potentially lower awards, Thomas Brinker and Maddie Ashton will have another problem in vaccine court, said their lawyer, Tobi Millrood. Like many children, they were diagnosed with autism more than three years after their vaccinations, beyond the time permitted to file under the program's rules.
   Some states, including Oregon, Florida, Louisiana, Illinois and California, had ruled that they had jurisdiction over Thimerosal cases, said John Kim, a Houston lawyer who argued against the government's request to close vaccine court records. "Now I guess this new provision in the Homeland Security Act trumps that," Kim said. Meanwhile, all Thimerosal cases have been put on hold at vaccine court while the court grapples with the scientific debate over the possible causes of autism. The Office of the Special Master, which oversees procedural issues at vaccine court, expects 3,000 to 5,000 filings.
   Parents outraged about the last-minute change point to Eli Lilly, the Indianapolis drug maker, as its biggest beneficiary. Lilly invented Thimerosal and manufactured it until the 1980s. The preservative is 50 percent mercury by weight, and had been used in vaccines since the 1930s. Lilly is a defendant in 200 Thimerosal-related lawsuits. "It's turned into being about money," Brinker said. "Parents with kids with autism don't have the money to give to congressmen. It turns out whoever has the most money wins."
   The provision in the Homeland Security bill was originally written by Sen. Bill Frist (R-Tenn.), a physician, as part of broader legislation aimed at helping drug companies produce vaccines after post-Sept. 11, 2001, concerns about smallpox and anthrax. The number of U.S. vaccine manufacturers has dropped to four, with companies complaining of low profit margins, manufacturing problems and fear of liability for injury.
   Edward G. Sagebiel, a spokesman for Lilly, said his company had no role in pushing the last-minute legislative changes. "We express sympathy for the parents and the children who have suffered adverse reactions," he said. "However, the lawsuits that have been filed against Lilly and other manufacturers are not supported by science."
   In 1999, the Food and Drug Administration conducted a review of Thimerosal and found no evidence of harm beyond limited cases of hypersensitivity to the vaccine. But the same year, the Academy of Pediatrics and the U.S. Public Health Service recommended that Thimerosal be removed from vaccines, partly out of fear that parents would stop immunizing their children and create a bigger public health problem. In October 2001, the Institute of Medicine, a branch of the National Academy of Sciences, said there was no evidence that Thimerosal caused autism, but it did say the theory was "biologically plausible." Most recently, on Nov. 30, the British medical journal the Lancet published a study showing that infants who received vaccines containing Thimerosal had levels of mercury in their blood that are within federal limits.
   Starr-Ashton remains unconvinced. "I don't believe anything that is 50 percent mercury by weight is safe," she said. She noted reports of health damage caused by mercury in fish, thermometers and dental fillings. "I'm not that dumb." The debate over science has become a furor over the democratic process in the tight-knit community of parents of children with autism that is linked by the Internet and community support groups. "Nobody is owning up to it," Brinker said. "It is so underhanded. I just can't believe our government would do this. We're not going to back down on this issue. We will not be silent."
   Starr-Ashton said she is not against vaccines, especially because she taught in a school for the deaf for many years: "I saw first-hand the damage done by rubella." But now she does not know who to trust. "Here I was, a dutiful parent taking my child to do what the government and the Academy of Pediatrics said I should do to protect my child against disease," Starr-Ashton said. "Something went terribly wrong. I need answers."

Supreme Court to Consider Foster Care Requirement
Heath Foster, Seattle Post-Intelligencer- 12/9/2002

It's been 10 years since Jenn Herrick left foster care, but she still trembles recalling the desolation she felt after she was separated from her four brothers and sisters at the age of 14. She was shuffled alone through four foster homes, ultimately ending up with an alcoholic foster mother who often told her she would never amount to anything. When her repeated requests to be reunited with her siblings were ignored, she stopped trying to make friends, and her grades plummeted. "It's a horrible, isolated feeling," said Herrick, now 28, tears clouding her pale blue eyes. "No one wants to hear what has happened to you. If you have an opinion, it doesn't matter. If you have an emotion, no one cares."
   For Herrick's little sisters, Mary Herrick and Lissa Herrick Osborne, their years in foster care were far from perfect. But they were allowed to stay together during that time, and they said they survived the experience by clinging to each other. They could "be each other's truth" because they shared the same scarred history, said Mary Herrick, 24, now a social worker in Seattle. "It was Mary and me against the world," added Osborne, 25, a legal advocate at a battered women's shelter in Everett. "Jenn has had the hardest life of us all, because she didn't have anyone."
   For decades, the psychiatrists, social workers and counselors who work with foster children have recognized the damage done when brothers and sisters are separated in the state's child welfare system. Now that system may be forced to change. In a case being watched nationally, the Washington Supreme Court is considering whether to require the Department of Social and Health Services to keep siblings together as they make their way through the state's chaotic foster care system.
   Of the nearly 6,100 Washington foster children with siblings in the system, 50 percent have been separated from at least one of their siblings. And 27 percent have been placed alone without any of their brothers or sisters, according to statistics kept by DSHS. They are separated in most cases for a simple reason: Washington has never managed to find the money and resources to recruit enough foster parents willing to take on intact families of troubled kids.
   For now, state Child Protective Services workers do their best to parcel children out to as few homes as possible, trying to take into account which brothers and sisters seem closest to each other. They say their choices would be less agonizing if they had the resources to keep siblings together. "We have to separate them, and it has troubled most of us in the field for a long time," said Dawn Cooper, the CPS administrator in Pierce County. Even when she is dealing with parents who are drug-addicted or abusive, if the agency's placement desk tells her she will have to put five siblings in five different homes, she says she thinks hard about removing them from the home. "It's easy to say from the outside they should simply be placed and protected," said Cooper, a social worker for 20 years. "I have to look at how attached they are to each other and how much they have relied on each other to get their needs met. "Sometimes their parents are so checked out emotionally that their siblings are the only emotional link they have . . . So, yes, they are in a bad environment, but do I have something better to offer them?" DSHS officials say they are trying hard to keep siblings together with limited resources. But they are fighting the reforms being sought in the Supreme Court case because they say it's unlikely that a Legislature facing a projected $2 billion deficit will come up with new money to make those reforms a reality.

What's at stake
The Supreme Court case is an appeal of a sweeping ruling by a Whatcom County Superior Court judge who ordered the state to make reforms to reduce the emotional damage many children suffer as they are shuffled through the foster-care system. The Whatcom County judge ruled in June that the state must create at least 500 new foster homes, provide mental health treatment for damaged kids, limit the number of moves foster children face and stop separating sibling groups, except when siblings pose a risk to each other. DSHS estimates those changes would cost $60 million over two years, forcing the agency to slash services for the elderly, the disabled and the troubled parents of foster children themselves. The biennual budget for DSHS' Children's Administration, which provides child protective services and foster care, is $847 million.
   Child advocates are uniformly dismayed by the state's stance, because experience has shown them that brothers and sisters would be spared a great deal of pain if they were kept together. "It is almost always in the best interest of children to stay together when placed outside the home," said Dr. Eric Trupin, a psychiatrist who directs the public health and justice policy division at the University of Washington's School of Medicine. Trupin said allowing brothers and sisters to stay together sustains their sense that they are still part of a family and that they have some control over their lives. Splitting them apart sends the message that they cannot depend on anyone. "Kids begin to relate to everyone as if they are the same, and don't think about the consequences of behaving in ways that are risky or negative," Trupin said. Many separated siblings turn to drugs and alcohol or start having children of their own too early, he said.
   Jim Theofelis is a Seattle mental health counselor who started the Mockingbird Times, a newspaper written by current and former foster children about the foster-care system. He said that when siblings are split up, they often lose the familiar roles that have allowed them to survive years of abuse. In many cases, the oldest child, usually a daughter, becomes the one who protects the younger kids, feeds them and helps them get off to school. If the parent-like sister is separated from her younger siblings, she worries about them as a mother might and feels incredible guilt for not being with them. And even if she is placed with caring foster parents, she may not know how to accept love and direction as a normal child would, Theofelis said. For younger children who depend on older brothers and sisters for love and stability, the separation can be equally devastating. With their protectors gone, they feel isolated and confused, he said.
   Amie Watkins, 20, of Everett, was taken away from her family at the age of 3 because her father had sexually abused her. Her family moved away soon after she was placed in care, and she never saw her mother or her brother, Andy, two years her elder, again. Watkins was never adopted. And as she made her way through a long series of foster and group homes, she often wondered how different her life would have been if Andy had been there with her. "If I met my brother today, he would be a complete stranger," said Watkins, now married and pregnant with her first child. "I have wanted to know if he was athletic, if he was smart, what his life was like living with my mom and dad. It's so devastating that I was separated from him, because he didn't do anything to me."

Quest to find each other
As foster children become older, finding lost brothers and sisters can become an obsession. That was the case for 16-year-old Cole, who entered Washington's foster-care system at age 2. His mother was a foster child as well, so badly abused by her own parents and her foster parents that she took refuge in heroin as a teenager. She ultimately had five children while addicted. Cole maintains that his mother, who is now off drugs, "always loved us deep inside." Cole's younger brother, Isaiah, joined him in foster care as an infant. The two boys were placed together for more than 10 years with a Covington pastor and his wife.
   From an early age, the boys say, they were beaten for misdeeds such as being unable to find a lost sock. The couple is now barred from taking in foster children while DSHS investigates the allegations. As the older child, Cole said he took the bulk of the abuse and finally decided at 12 to move out. He landed in a loving new foster home in Kent. Around that time, he learned that his mother was pregnant again, and he kept track of her through friends. When his baby sister was found abandoned about a year later, he persuaded his Kent foster mother to help him track down the baby in the foster-care system. Monica, now 3, came to live with Cole's new family soon afterward. Meanwhile, back at the Covington foster home, Isaiah said he was being beaten more regularly. After one particularly vicious beating earlier this year, he too left. He was welcomed into Cole's foster family in September. Their current foster mother, a deeply religious woman, said watching the three siblings' relationships blossom has been nothing short of a miracle. "They just connect like magnets," she said.
   Their reunion is somewhat remarkable because it is not mandated by law. Earlier this year, the state Legislature passed a law that required judges, social workers and foster parents to arrange for regular visits and phone contact between foster siblings who must be separated in care. But the new requirement does not apply once the rights of the children's birth parents have been terminated, or once children are adopted or have found a legal guardian." There is nothing legally to make the new parents who have adopted a child have visits with their siblings," said Linda Lillevich, who represents parents and children 12 and older in dependency proceedings for The Defender Association, a non-profit firm that provides public defense in King County. "Morally, it seems like they ought to have contact."
   That problem has kept Cole and Isaiah from being reunited with their youngest brother, 11-year-old Justin, whose foster mother has become his legal guardian. Through a state social worker, they received word in August that she had an opening in her home and was hoping to fill it with one of Justin's siblings. But after learning that his two brothers and sister were in a happy, lasting placement, she was not willing to let Justin see them. Cole has had a hard time accepting her decision. "It's my dream . . . what I have been praying for, to live with my (siblings) instead of in separate homes," he said.
   Lillevich said that when children ask her for help getting in touch with adopted brothers and sisters, the best she can do is ask a caseworker to check whether the adoptive parent is willing to make contact. But many adoptive parents who have done the hard work of making a troubled foster kid part of their family often worry that contact with a brother or sister still stuck in the foster-care system will destabilize their child. Interestingly, data collected by the Seattle-based Casey Family Foundation in collaboration with the Massachusetts Department of Social Services show that brothers and sisters who are kept together when they are first placed in foster care are less likely to face multiple moves.
   Fran Gutterman, who directs a foster-care-system reform effort for Casey, said a Boston pilot program found that well-supported foster parents who took in large sibling groups became more willing to hold on to one particularly difficult child. "They see the connection (the brothers and sisters have) and respond to it as caregivers," she said. Social workers and other professionals who work with foster children confirm that once brothers and sisters are placed separately, reuniting them is difficult if they don't end up returning home or going to live with relatives. Often, one set of siblings is in a home they like, and so it seems wrong to move them. Especially troublesome are situations in which one child adjusts well to a home, but a brother or sister -- usually older -- battles with the foster parents, social workers say. The older child wants to be moved, but should the younger child's life also be disrupted so he can stay with his or her sibling?
   In Pierce County, a new receiving facility for foster children called Cedar House is working to ensure that siblings can stay together when they come into the system, rather than be sent to multiple homes immediately after being taken from their parents. The facility can take as many as 12 children for up to 30 days. Cooper said it gives social workers time to scour the system for a placement that will stick. Unless the state Supreme Court mandates that the state create more places such as Cedar House, many foster children will have to wait until adulthood to have control over how much they can see their siblings.

Home again
Perhaps not surprisingly, the insatiable drive foster kids have to know their families does lead to many reconnections once they leave the system. The Herrick siblings have that happy ending to their story. The girls were placed in foster care a few years after it came to light that their father had been sexually abusing them. Their mother, a caring but damaged woman, found that she was not able to care for her five children after he was gone.
   While Jenn Herrick was bounced through various homes, Osborne and Mary Herrick were placed together, first in the home of a loving school librarian and later with an aunt and uncle. They went on to get college degrees and pursue professional careers. "I have felt really seriously guilty, because we had so much more opportunity than (our brothers and sister) had," Mary Herrick said. Jenn Herrick moved to Arizona after she graduated from high school, worked odd jobs and had her first child at 21. She has supported herself as a child-care provider and has been working toward a degree in early childhood education by taking community college courses at night.
   Just before Thanksgiving, Jenn Herrick moved to Seattle with her 6-year-old son and 1-year old daughter to be closer to her sisters, who live in Seattle, and her two brothers in Tacoma. She and her kids will be living with Mary Herrick, Osborne and Osborne's husband in their Greenwood apartment until she gets on her feet. "It's really good just having family," Jenn Herrick said.