Even Under State's Protection, Many Children Are Dying
Ruth Teichroeb, Seattle Post-Intelligencer- 4/12/2002

Nicole Marie Embum's only defense was her sweet smile. Before she was even born, her pregnant mother was reported to Child Protective Services in Lewis County for using methamphetamine. More anxious calls would follow. Nicole couldn't even sit up on her own when relatives began begging the CPS to intervene. The 17-year-old mom carried a syringe in the baby's diaper bag, ran with a man almost three times her age and ignored Nicole, the relatives reported a year ago. Caseworkers said they couldn't take the baby away. They couldn't prove neglect.
    Strung out on meth one night last May, the young mother fell asleep on the couch she was sharing with Nicole. She rolled over and smothered her 4-month-old daughter. The next morning, another adult noticed Nicole was missing; she rolled the slumbering mother off the tiny body. No criminal charges were filed. The death was deemed accidental by local authorities and the state Department of Social and Health Services. But some of those who loved Nicole believe she could have been saved. "We all knew something was going to happen," said Eloise Pugh, Nicole's paternal grandmother, who looked after the baby when the young mother allowed it. "They wouldn't do anything."
    Over the past five years, parents and caregivers across Washington have fatally abused and neglected dozens of children like Nicole who are supposed to be protected by the state. In many cases, children perished in homes child-protective workers knew were unsafe. And the state does not even know how many children have died because of its failure to track or properly review the deaths -- even as the toll rises to record levels.
    The state acknowledges that abuse or neglect killed 29 of at least 460 children who have died since 1997, after their families became embroiled with Washington's child-welfare system. But the problem is far worse than state officials admit. An investigation by the Seattle Post-Intelligencer has found that abuse and neglect have killed at least 107 children over the past five years. While the number of abuse-related deaths has remained fairly steady, neglect-related deaths have more than tripled over the past two years. "Kids are dying because we aren't getting them into good care," said Steve Wickmark, director of the Children's Alliance, a statewide advocacy group. "It's a frightening thing and it shouldn't be happening."
    Eight out of 10 children who lost their lives because of abuse or neglect were 5 years old or younger, according to a computer analysis of 365 DSHS child-fatality reports obtained through public disclosure. Dozens of other fatality reports could not be located, agency officials said. One-quarter of the younger children were fatally abused; neglect figured prominently in the deaths of the rest of the 107, the records show. Among older children, 12 percent died after being abused or neglected. Of those, one out of four deaths were due to physical assaults. Almost as many teenagers died in street-related violence or at the hands of acquaintances. Those deaths weren't classified as related to abuse or neglect -- even though many victims came from troubled families. Suicides also were excluded.
    Deaths were attributed to fatal neglect if parents or caregivers caused the death by failing to meet a child's basic need for food, shelter, supervision or medical care, or through recklessness. That included parents who left babies to drown in the bathtub, ignored medical care for sickly infants and killed children while driving drunk. Most of the neglect-related deaths were considered to be accidents or natural deaths by the DSHS and county medical examiners or coroners. The deaths most likely to be prosecuted involved physical abuse; about one-third of those cases went to court.
    State officials say child-welfare workers do their best to keep watch over troubled families, but not every child can be saved. One of the weakest child-neglect laws in the country hinders the state's ability to remove children, and a chronic shortage of resources makes their job tougher, they say. But in many cases reviewed by the P-I, obvious warning signs went unheeded. Two CPS reports had been filed on the family of 11-month-old Oneal Gamble Jr. in the year before his body was found face-down on a teddy bear in a Seattle crack house last September. A crack pipe was found next to the infant's body. Tangled in his hair was the pipe's wire-mesh filter. Oneal died after swallowing a lethal amount of cocaine, the autopsy determined. In the months before he died, the CPS had assigned a caseworker to the family because of concerns about one of Oneal's three older siblings. The DSHS deleted details of the family's decadelong history with the CPS from Oneal's child-fatality report. There were a total of 20 complaints filed, but none was specifically about Oneal, said Bob Stutz, a Seattle official with the Children's Administration, the DSHS' child-welfare branch. Although police told the CPS the mother was living in a crack house, Stutz said that wasn't enough to prove in court that Oneal was in danger. "She was responding to drug treatment at the time he died," Stutz said.

Scrutiny of child deaths lacking
One night last June, a 2-month-old Hoquiam baby died of sudden infant death syndrome. In the hours before he died, his drunken mother had been brawling with her partner so loudly that a friend offered to take the baby home. The mother refused. Nicole Embum's grave, 12 miles east of Morton, is decorated with flowers, dolls and a flag. Nicole died after her drug-abusing mother rolled onto her in her sleep.  Two hours after the friend and the mother's partner left, the baby was dead. The mother was too intoxicated to explain what had happened to her son. The family had 41 previous CPS reports, and the mother, who had a history of substance abuse, had already relinquished her parental rights to three other children. CPS workers had considered removing the fourth baby at birth, but decided to provide intensive monitoring instead. She deserved another chance, they believed.
    About 70 percent of the families in which younger children died of maltreatment had been reported two or more times to the CPS, records show. Many families had 10 or more referrals in the years before a child's death. Nearly one out of four families had open CPS files when a young child died of abuse or neglect. That meant caseworkers were actively investigating concerns about the children's safety. "A system that protected children really should intervene earlier. Neglect is devastating," said Kathy Carson, a King County health department administrator. Carson coordinates a King County child-fatality team that reviews all unexpected deaths of children.
    The causes of death are wide-ranging. Here's a partial breakdown:
* Twenty-eight young children were beaten, choked or suffocated by parents or caregivers, including two day care providers.
* Nine newborns died after fetal abuse by drug-abusing mothers.
* Thirteen parents crushed their infants in bed, with substance abuse a factor in half of the cases.
* Three babies died of drug overdoses.
* Fifty-seven babies died of SIDS -- a rate more than twice the statewide average.
* Nineteen children drowned -- eight of them young children who were left unsupervised.
* Seventeen children died in house fires, at least six of those involving neglect or substance abuse.
* Thirty children died in car wrecks, at least nine involving alcohol abuse, reckless driving and a failure to use seatbelts.
* Seventeen children committed suicide, including two 10-year-old boys.
* Fifteen teenagers were killed in street violence or by acquaintances.
* In at least 15 more cases, the cause of death remains "undetermined."
    The DSHS has done little to learn from the tragedies. Over the past five years, child fatalities have not been systematically tracked by the DSHS, let alone reviewed adequately. Records are in disarray. "We certainly recognize we have some tracking issues," said Sharon Gilbert, a Children's Administration official, adding that a new database will soon help. Only high-profile child deaths, such as the beating of 3-year-old Zy-Nyia Nobles in Tacoma two years ago, have rated careful scrutiny by the DSHS. Zy-Nyia died after being sent home to her violent mother.
    Caseworkers are required to file a fatality report if the victim's family had contact with the DSHS in the year prior to the death, or if the child died in a licensed facility, such as a day care center. An in-depth report must be done with 30 days. The DSHS could not find many of the reports prior to 2000. And the P-I investigation found that 45 more children have died in the last two years than the state even realized. DSHS policy also requires an independent review of unexpected child deaths, including those attributed to SIDS and accidents. That review used to be done by a team of community representatives.
    In 1999, the DSHS dropped the independent-review process, leaving that task to county-run child-fatality review teams that were just getting started. The county teams, convened by health departments, review all unexpected child deaths and make recommendations to the state Health Department. The county teams, however, are prohibited by law from reporting on specific cases to anyone, including the DSHS. So for the past three years, there's been no detailed, independent scrutiny of the DSHS' handling of child deaths. "That is a serious concern," said Vickie Wallen, the state's ombudsman for families and children. "They're shuffling off their responsibility to someone else." Bruce Thomas, a DSHS official, said county child-fatality teams could provide objective fatality reviews if the reporting ban were lifted. State attorneys, he said, are working on the problem.

State failures lead to deaths
In a crisis-driven child-welfare system, neglect doesn't attract the same attention as bruises or broken bones. A December 2000 CPS report that 17-year-old Yesenio Acevedo was homeless and drifting from place to place with an infant prompted little action. Child-protective workers knew she was a high-risk parent with her own history of neglect as a child. Carlos Saldivar, a supervisor in the Yakima child-welfare office, said the teen mom was offered help but didn't respond, and they lost track of her. Last September, Acevedo and her toddler moved in temporarily with the Yakima family of her boyfriend, 16-year-old Esteban Leon. The family was well-known to the CPS -- at least two siblings had been removed from the home in the past. Within weeks of moving into Leon's home, Acevedo's 22-month-old son, Luis, was dead. Leon later admitted to choking and beating the boy to death after his girlfriend spurned him. He pleaded guilty to first-degree manslaughter and received a seven-year prison sentence.
    If CPS workers had responded to a complaint involving Leon's family shortly before Luis was slain, they might have discovered that Acevedo and her son were living there. An internal review concluded the complaint should have been investigated, but the DSHS withheld details. An autopsy showed that the fatal beating wasn't the first time Luis had been abused. Burn marks were found on his arm.
    When the state does remove children, relatives are often used as foster parents. But at least six children died after relatives handed them back to dangerous parents and the state failed to follow up, records show. Caseworkers with the Spokane Tribe removed Jamesetta Shealeay's three little boys twice in the year before their death, placing them with relatives on the reservation. Shealeay's track record was grim -- she'd accidentally killed her twin babies in 1995 by leaving them next to a 100-degree space heater. They died of heat exhaustion. But when a relative violated a court order by returning the boys to Shealeay in January 2000, tribal caseworkers did not intervene or alert state child-welfare workers. On Jan. 16, 2000, she drugged her sons with cough medicine at their Spokane home so she could go out drinking, prosecutors say. When a fire broke out that night, William, Malcolm and Anthony, ages 2, 5 and 6, didn't have a chance. Shealeay pleaded guilty to three counts of manslaughter last summer. She is now serving a 3 1/2-year sentence.

'Bad things will happen'
Sometimes there was little the state could have done to save young lives. The CPS was told that a Bremerton mother with a substance-abuse history was using illicit drugs during her pregnancy last year. But under state law, they couldn't force her to stop. Her baby died after being born prematurely. "Bad things will happen to children," said Ross Dawson, deputy assistant secretary for the Children's Administration. "You can't prevent every death in the world."

Social workers investigate some 40,000 CPS complaints a year in families racked by poverty, substance abuse and domestic violence. Predicting which parents will explode in rage at a crying baby or get high while their toddler falls into a neighbor's pool is far from an exact science. Child-protective workers say they are also handicapped because Washington is one of only five states that insists on proof of imminent harm before a child can be removed from parents. "Society is clear where to draw the line with physical abuse and sexual abuse," Dawson said. "On neglect, we're not clear. ... Wherever society draws the line, the state intervenes." That's often an impossible standard to meet when it comes to chronic neglect. "I think everyone agrees more of a hammer is needed to turn these families around," said Wallen, the ombudsman, whose annual report a year ago called for a stronger neglect law.
    A bill that would have given the DSHS more leverage with neglectful parents failed to pass the Senate last month amid concerns that it might tread on parental rights. Legislators did pass a tougher criminal-mistreatment law that police can use when parents' neglect puts children at risk of harm. The fourth-degree misdemeanor allows for deferred prosecution if the accused seeks treatment.
    Part of the reluctance to point the finger at parents is society's attitude that accidents or illnesses can happen to anyone, said Dr. Howard Dubowitz, a Baltimore pediatrician and child-abuse expert. Still, the death of a child after multiple neglect reports should raise serious concerns for state child-welfare agencies, Dubowitz said. "To write those off as accidents is ridiculous."

Second chances lead to tragedy
Ten-month-old Khadija Ali's name isn't on any list of neglect-related deaths. She officially died of pneumonia in October 2000. But a closer look at her family's history reveals longstanding concerns about neglect. A CPS worker closed the agency's file on Khadija less than two weeks before the baby's body was found on the floor in a filthy, unfurnished Kelso apartment. Suffering from a possible ear infection, Khadija cried inconsolably the night before she died, according to police. Her mother and a boyfriend shut the baby alone in a room. Clad only in a diaper, on a makeshift bed of blankets on the floor, Khadija's cries soon stopped. Four hours later, the mother and her boyfriend awoke and took a one-hour bath together, police reports said. The coroner blamed pneumonia for the death, but said he couldn't rule out accidental suffocation. The baby was found lying near a plastic bag.
    Equally unclear is why the mother still had custody of Khadija. During the pregnancy, the CPS briefly removed the mother's two older children after police found her passed out on a couch in an apartment strewn with drug paraphernalia, beer cans and garbage, a DSHS report says. The mother promised to get drug treatment and take parenting classes. Her children were returned, although she completed neither requirement. Another neglect report prompted the CPS to remove Khadija from the home in March 2000, but a judge ordered the baby returned pending a custody ruling. The mother promptly vanished with the baby. She didn't show up again on CPS radar until six months later, when she was again accused of physical and medical neglect. She begged for another chance, saying "things are different now." She began drug treatment. On Oct. 12, 2000, her CPS caseworker met with other community professionals, told them Khadija "does not appear to be at high risk" and agreed the case should soon be closed. Nineteen days later, Khadija was dead.
    Part of the problem with preventing neglect-related deaths is even experts don't agree on a definition. As a result, the deaths are dramatically underreported, according to Marcia Herman-Giddens of the North Carolina Child Advocacy Institute, former head of the state's child-fatality team. She cited the case of a toddler who drowned in a pond after being left alone for 30 minutes. "To my surprise, half the team disagreed that that was neglect," she said.
    When children die after contact with the child-welfare system, the state has a duty to investigate in order to help prevent further deaths, she said. In North Carolina, such deaths undergo three intensive levels of investigation: an independent community review by the state child-welfare agency, plus county and state child-fatality team reviews. Of the 800 children who die each year in Washington, about half are "unexpected deaths," subject to review. A third of those families had at least one CPS referral.
    Last year, King County's child-fatality team raised concerns in its annual report about "the proportion of deaths reviewed in which there has been CPS involvement, substance abuse, chronic neglect and involvement by either the child or family with the criminal justice system." Carson, the team's coordinator, said it takes an average of 17 CPS referrals before the DSHS takes action. "It's an ongoing concern that the state doesn't take the first red flag on this family and do something," she said. "We don't seem to be able to act until disaster occurs."

'We can't just let it go'
The CPS caseworker assigned to protect Nicole Embum never met her. On Dec. 16, 2000, two days before Nicole's birth, the worker visited her teenage mother, checking on a complaint that she was using meth -- bragging about "doing a line" before a doctor's appointment. But the mother denied using drugs and no action was taken. After having Nicole, she drifted between the homes of relatives and friends in rural Lewis County. The teenager was barely out of her own tumultuous childhood, which included nine CPS reports dating back a decade. "She's not had a chance in her life either," said Pugh, the grandmother. "She wants to change, but she needed protection, too." Reached at home, the mother, now 18 and pregnant again, refused comment.
    Nicole was just 3 weeks old and suffering from a viral infection when her mother moved in with Pugh, who helped nurse the baby back to health Eloise Pugh hugs her granddaughter Justine, 8, at her home. Another granddaughter, Nicole Embum, 4 months old, died in May while her mother was strung out on meth. "We all knew something was going to happen," Pugh says. "She was a happy little baby," Pugh recalled. "She laughed and played."
    On March 13, 2001, Pugh reluctantly called the CPS and the police to complain that Nicole's mother was "back into drugs" and had taken up with a much older man. The caseworker made a few calls and decided the baby wasn't at risk. Three weeks later, Nicole's father, Cody Embum, reported to the CPS that he'd found a hypodermic needle in Nicole's diaper bag during a visit. He said he was "worried something will happen to the baby while mom is doing drugs," according to a state report. The caseworker phoned relatives but reported being unable to locate the baby. "Certainly we were concerned," said Mike Crowe, a Children's Administration regional administrator. "But we're at a disadvantage with people who are difficult to find." The night of May 10, relatives frantically called the CPS and police to say that Nicole's mother was high and had refused to leave the child with them. Within hours, the baby was dead. Pugh now wants the truth to come out. "If it will save some other baby," she said, "we can't just let it go."

N.J. Doctor Files Class-Action Lawsuit Against HMOs
Jeffrey Gold, Associated Press- 4/12/2002 20:45

NEWARK, N.J.-- A New Jersey doctor filed a proposed class-action lawsuit Friday against four of the state's largest health maintenance companies. Dr. John I. Sutter charged they routinely shortchange thousands of physicians through late or improperly reduced payments. He said that patients are hurt because HMO practices inhibit and prevent doctors from providing the best care. ''It is almost impossible to comply with the demands of the insurance companies,'' said Sutter, a 20-year pediatrician who has 5,000 patients at his Clifton practice. For example, vision and hearing screenings, a normal part of a check-up, are either not reimbursed or are at such a low rate that it costs the doctor money to provide, Sutter said.
    Sutter's lawsuit is believed to be the first of its kind in New Jersey, said his lawyer, Eric D. Katz. Accused are Horizon Blue Cross Blue Shield of New Jersey Inc., based in Newark; Cigna Healthcare of New Jersey Inc., of Rockaway, a part of Cigna Corp, of Philadelphia; United Healthcare of New Jersey Inc., of Fairfield, a unit of United Healthcare of Minnetonka, Minn.; and Oxford Health Plans Inc., of Trumbull, Conn. None of the companies had seen the lawsuit Friday, and none had an immediate comment. The case was filed in state Superior Court for Essex County. Few of the 20,000 doctors in New Jersey can afford not to join a managed care network, said Dr. Angelo S. Agro, president of the Medical Society of New Jersey. ''Patients go where their insurance goes,'' Agro said.
    The Sutter lawsuit seeks to be certified as a class action. It seeks unspecified compensation for denied, delayed or reduced claims and money to punish misconduct. The sum could total ''many millions of dollars,'' Katz said. It claims the four companies operating in New Jersey violate the state's prompt payment statute, which requires that claims be paid within 30 days or accrue interest.
    Katz also claimed the HMOs violated by state's Consumer Fraud Act by engaging in ''a pattern of deception'' in their contracts. ''They hook in these doctors, who have no choice anyway, and make claims that they will pay off promptly,'' he said. The lawsuit also charged that the insurers regularly and improperly ''downcode'' doctors' claims, making it appear the doctor performed a simpler procedure, so they can pay less.
    Horizon Blue Cross has about 13,000 doctors in its HMOs, which have about 1.25 million patients, spokesman Fred Hillmann said. Cigna Healthcare has about 19,000 New Jersey doctors in its Network, and about 565,000 patients in managed care programs, said spokeswoman Patricia Caballero.
    Insurance companies, including some of those in the Sutter suit, have been targets in other class-action lawsuits: 29 Texas physicians sued Cigna Healthcare of Texas Inc. in October, claiming the health maintenance organization is unfairly and purposely refusing to pay for valid medical services. Patients and doctors have twin actions pending in federal court in Miami against leading managed care companies Aetna, Cigna, United Healthcare, Humana, Prudential Healthcare, Pacificare, Wellpoint Health Networks and Health Net. Kansas physicians claim they were cheated out of money owed them by a health maintenance organization, Kaiser Permanente, that plans to leave the Kansas City area. A Connecticut judge approved a class-action lawsuit in July by about 7,000 doctors against a health maintenance organization, Anthem Health Plans Inc., which is accused of breach of contract and unfair trade practices. In New Mexico, St. Joseph Healthcare won dismissal in September of a lawsuit filed by senior citizens who contended its Medicare-Plus plan subjected them to bait-and-switch tactics.

On the Net:
Cigna: http://www.cigna.com
Horizon: http://www.bcbsnj.com/ Oxford Health Plans: https://www.oxhp.com/
United Healthcare: http://www.unitedhealthgroup.com/

Study Suggests Dyslexics Have More Suicidal Thoughts
Melinda T. Willis, ABC News- 4/12/2002

Dyslexia is not just a reading problem. New research suggests that it may also be connected to a young person's thoughts about suicide. Preliminary results of a new study, presented this week at the meeting of the American Association of Suicidology in Bethesda, Md., find that teenagers with dyslexia are more likely than normal readers to think about and attempt suicide.
    Researchers enrolled 94 students who had reading problems and 94 similar subjects who were considered normal readers based on performance on a reading test taken at age 15. The study found that 19 percent of students who were poor readers had a history of either suicidal thoughts or attempts compared to 5 percent of students who were normal readers. Researchers also found that kids with reading problems were 10 percent more likely than normal readers to drop out of school, and that suicidal thoughts were strongly related to dropout rates.
    Suicide was the third leading cause of death in 1999 for those aged 15 to 24, according to the National Institute of Mental Health. "It's much more than a reading problem," says Dr. Theodore Petti, Arthur B. Richter professor of child psychiatry at the Indiana University School of Medicine in Indianapolis. "These youngsters are certainly at risk for suicide."

A Vicious Cycle
Experts say the typical challenges of adolescence and young adulthood can be even more pronounced for those with learning or reading disabilities, largely due to the significant importance and influence of academics in adolescent life. "Poor academic performance raises questions about if they are going to finish school or what they are going to do after they finish school — what kinds of jobs they are going to get," says David Goldston, lead researcher on the new study. Goldston is director of the child and adolescent mood disorders and suicidal behavior clinic at Wake Forest University School of Medicine in Winston-Salem, N.C.
    And poor performance in school because of a reading disability can lead to feelings of depression and anxiety that further serve to perpetuate poor performance, experts add. "Some adolescents with dyslexia have difficulty expressing themselves and so they are made fun of and they start to withdraw and they don't keep up," says Petti. "It's a very negative cycle of failure after failure. It's not surprising for these individuals who have average or above-average intelligence to feel very frustrated because they are not able to read as well as they should be."

Help and Prevention
Experts say that one of the keys to combating the frustration and poor academic performance that result from reading problems is to recognize and identify possible problems as early as possible. "We need to provide these youngsters early on with an awareness that they have a difficulty and provide them with some additional help to counter it," says Petti.
    And experts agree that these efforts can extend beyond offering reading help. "Prevention and intervention efforts for dyslexic youth should probably focus on or be aware of the psychological pressure that comes to these youths from the school experience," says Goldston. "I am pleased that this research is bringing back the awareness that there is a cycle in academics between performance and psychological effects and that these are interacting factors that play on each other," adds Petti.

Prosecutor Says McDermott Is Faking
Michele Kurtz, Boston Globe- 4/13/2002

CAMBRIDGE - In the years before he shot to death seven co-workers, Michael McDermott searched the Internet for articles about faking insanity and bought a book on how to determine whether someone is pretending to be psychotic, he acknowledged under cross-examination at his murder trial yesterday. Prosecutors, trying to dismantle McDermott's assertion that he was schizophrenic and hallucinating when he killed his colleagues on Dec. 26, 2000, portrayed him as a clever master of fantasy games who planned the shooting spree and is now making up a bizarre explanation.
    ''After 20 years of playing these games, after many years of lying to doctors, after doing research on how to fake, on studying the tests on faking and malingering, you're very good at concocting fantasy tales, aren't you?'' Middlesex Assistant District Attorney Thomas O'Reilly asked. ''I said I never fake symptoms for a doctor,'' McDermott replied.
    Later, two psychiatrists who had treated McDermott years before the killings testified for the defense that they had diagnosed him with depression and an obsessive-compulsive personality, but at the time did not consider him psychotic. One psychiatrist said that in 1987 McDermott told her he heard loud noises coming from the television when the volume was turned down.
    McDermott, 43, of Haverhill returned to the witness stand in Middlesex Superior Court yesterday and again appeared calm, lucid, and often glib. Yesterday when O'Reilly accused him of pretending to be mentally ill, McDermott said, ''Of course not.'' O'Reilly asked him whether he had visited a Web site called ''By Reason of Insanity,'' to which McDermott said, ''Absolutely.'' O'Reilly showed jurors a printout of a Web-search request in which McDermott had typed ''how to fake mental illness.'' McDermott acknowledged that in 1999 he purchased the book, ''The Clinical Assessment of Malingering and Deception,'' a reference book used by psychiatrists and psychologists. But he said he hadn't read it because the book was too difficult to understand, an answer O'Reilly scoffed at, given McDermott's intelligence. McDermott has testified that his I.Q. has registered as high as 165.
    Questioned later by his own lawyer, Kevin Reddington, McDermott said he researched how to fake mental illness to learn how to pretend to doctors that he was normal. McDermott has said that he had distrusted psychiatrists since childhood and that he concealed hallucinations and delusions from them.
    Prosecutors contend that McDermott killed his co-workers because he was angry that Edgewater planned to seize part of his wages at the request of the Internal Revenue Service. McDermott told his supervisors they didn't have to comply with the IRS, which he said he'd paid. O'Reilly said McDermott had called Cheryl Troy, one of the victims, and others ''Nazis'' when they said they had to do as the IRS ordered them. ''The company was attempting to use the same defense the Nazis used in Nuremburg: `I'm just taking orders,''' McDermott testified under cross-examination.
    Dr. Ann Schwab, a psychologist who treated McDermott for several months after he tried to kill himself in Maine in 1987, said he frequently wept in her office during their weekly appointments and referred to himself as paranoid. Under cross-examination by Middlesex District Attorney Martha Coakley, Schwab laughed nervously and acknowledged that in a deposition in a lawsuit filed by McDermott she had said she did not believe he was psychotic.
    Dr. Alan Rothstein, a Brookline psychiatrist, testified that he treated McDermott for the four years before the killings. He diagnosed him with major depression and prescribed Prozac. He had tripled McDermott's dosage by 2000. During their sessions every six weeks or so, Rothstein said, McDermott did not exhibit signs of psychosis. In March 2000, McDermott told him he was having problems with credit card debt and went on to say, ''I have guns.''

Sex Abuse Researchers, Therapists Fault Church & Society
Jeff Donn, Associated Press- 4/13/2002

BOSTON -- Every week seems to bring another awful revelation. Roman Catholics are accusing dozens of priests of abusing them as children or teen-agers. Lawsuits mount. Bishops turn over names to prosecutors. How could so much sexual exploitation of children no less turn up within a church? But how much is there, really?
    Frustratingly, there is no definitive research on the frequency of such abuse in either the church or society. Few abusers will talk. Some tentative research, though, tends to support what many church defenders have long said: Priests may abuse children and underage teens no more than other men do. Here's the sticking point, though. Whatever the relative rates of abuse among priests and ordinary men, abusive priests tend to show particular characteristics and tend to abuse in distinct ways, other research suggests. Such studies help support the theories of many researchers and therapists who believe celibacy, the power of the priesthood, and cover-ups by centralized church authority contribute to the problem of sex abuse among priests.
    One of the first efforts to study the rate of child abuse in the church came in a 1992 Canadian survey by John Allan Loftus and Robert Camargo. They studied 1300 Catholic priests and brothers at one treatment center. They found that 2.7 percent had sex with children up to age 13 (a sexual disorder known as pedophilia) and another 8.4 percent with teen-agers up to age 19 (an offense called ephebophilia). However, the study subjects were not representative of the whole priesthood.
    Other researchers, including those within the church, have offered lower estimates. A study by the Chicago Archdiocese looked back at personnel records of 2,252 priests over 40 years. Only 40 of them about 2 percent were reported as offenders, according to Philip Jenkins, a Pennsylvania State University historian who has studied sexual abuse in the priesthood.
    Sex abuse in the general population a much bigger group is even harder to estimate. Researchers usually base their calculations partly on victims' reports, which are viewed as more accurate than those of offenders. Using such data, Canadian psychiatrist John Bradford estimated last year that 6 percent of adults may be pedophiles. Other researchers put the combined rate of pedophilia and ephebophilia among men the overwhelming majority of abusers anywhere from 2 to 9 percent.
    Such widely ranging numbers suggest the problem is big in the priesthood and beyond. But they do not demonstrate that there is a broader problem in the priesthood than in society at large. Why, then, do news reports almost uniformly give a strongly opposite impression? A spokesman for the U.S. Conference of Catholic Bishops declined public comment. But the church's defenders see several explanations. For one thing, the Roman Catholic church is by far the country's largest denomination, with about 45,000 priests and 62 million followers 22 percent of the American population. It makes an attractive financial target. Kevin Gillespie, a Jesuit priest who teaches pastoral psychology at Loyola College in Baltimore, sees an element of hysteria in the scandal. ''It's not to say that people haven't been abused,'' he said. ''I don't think it's any worse or any better than most walks of life.''
    A striking fact remains: While abusers exist in many denominations, no other major American church has confronted a sex abuse scandal of this magnitude. Whatever their numbers, abusive priests seem somewhat different than other offenders: older, better educated, especially strong in denying their misconduct. Their abuse generally comes to light later. Their victims are far more often male.
    In a 1996 study, researchers at Rush-Presbyterian-St. Luke's Hospital in Chicago studied records from 69 admitted molesters of minors, including 24 priests, from a sex clinic at the hospital. The priests were evaluated as less mentally ill, but more sexually conflicted than other abusers.
    Terry McDonough, of Duxbury, Mass., a married priest suspended from official duties, says too many priests are frozen in their sexual development from their first days in seminary. ''I definitely was sexually immature when I started, because I was 13 years old. I definitely was sexually immature when I was ordained at 26, because I had no connection with women,'' says McDonough, now 66 and the father of two children. Today, seminarians typically begin training at a later age but are too often undeveloped emotionally, some researchers say. Young men who start out as sexually or emotionally immature or confused may flee their conflicts by seeking the protection of celibacy, the theory goes.
    Some potential abusers are attracted to the power of the priesthood, according to Gerard McGlone, a psychologist at Johns Hopkins University. ''Most priests go into the clerical life because they want to serve. Most sex offenders go into the clerical life because of power needs,'' says McGlone, who is also a Jesuit priest.
    The powerful, centralized church bureaucracy may have magnified problems by shifting abusers to new assignments and settling cases quietly, some researchers and counselors also suggest. Some church critics view the church differently than society. ''I certainly do hold the church to a higher standard,'' says David Clohessy, who says he was abused by a priest and now runs the Chicago-based Survivors Network.

Young Smokers Hooked in Few Weeks, Study Says
Stephen Smith, Boston Globe- 4/15/2002

Adolescents can become addicted to cigarettes in as little as a few weeks by taking just a few draws on a cigarette every other day, according to new research from the University of Massachusetts that demonstrates how quickly nicotine cravings can foster a life-threatening habit. Dr. Joseph R. DiFranza, the University of Massachusetts medical school professor who directed research that appears in this month's issue of Archives of Pediatrics & Adolescent Medicine, recalls performing a physical exam on a 14-year-old girl who had begun smoking at the start of summer. ''I told her, `You should quit before you get hooked.' And she said, `It's too late,''' said DiFranza, a family medicine specialist at UMass Memorial Healthcare hospital in Worcester. ''It hadn't even been two months, and she had already tried to quit and wasn't successful. We found that her experience was not unusual.''
    To help adolescents recognize when they have a cigarette addiction, DiFranza and his Worcester research team created the 10-point Hooked on Nicotine Checklist, which asks about cravings, the inability to stop smoking, and behavior changes. DiFranza said he hopes the survey will turn up on the pages of teen magazines such as Seventeen. The researchers discovered that if teens answer even one of the questions affirmatively, they're already addicted and will find it difficult to kick the habit. ''We were quite shocked ourselves,'' DiFranza said. ''We thought that the kids that were developing symptoms so quickly were going to be the extreme examples. The opposite turned out to be true; kids that were developing symptoms of addiction within a few weeks of starting smoking were the rule rather than exception.''
    The UMass team is completing the data on precisely how long it takes for adolescents to become addicted and expects to release those findings in a few months. The researchers tracked 679 seventh-graders for 21/2 years, conducting eight interviews with each of them. The study published in the pediatric medical journal reports that, compared with other smokers, youths with at least one of the checklist symptoms were 29 times more likely to fail in efforts to quit, 44 times more likely to still be smoking at the end of the study, and 58 times more likely to have progressed to smoking every day.
    The director of the Massachusetts crusade to stop children from smoking said the study demonstrates powerfully the importance of tailoring prevention campaigns to adolescents. In television advertisements, the state's Tobacco Control Program has aimed to persuade youths that smoking translates into giving up control. ''The last thing a 13-year-old wants to think about is some tobacco company controlling their behavior, so we get them to rebel against a tobacco company instead of a teacher or a parent,'' said Gregory Connolly, director of the Massachusetts Tobacco Control Program at the state Department of Public Health. ''We've got to identify the high-risk kids and intervene.''
    The need for that type of intervention was indicated in 1993, when state researchers discerned a surge in smoking among middle school students. The durability of the habit was evident in 1996, when an upswing was reported among high school students, essentially, the same group that had started smoking three years earlier. There was proof again last year, when that cadre of smokers reached adulthood; in 2001, more people between 18 and 24 smoked than any other age group. ''It was the Joe Camel and Marlboro days when they started smoking, and it was when smoking came back into Hollywood,'' Connolly said. ''We're still paying that price.''

Divorce Can Often Have Devastating Financial Consequences
Catherine Valenti, ABC News- 4/16/2002

Lisa Bell knows the financial struggle of divorce all too well. Bell, a 35-year-old public relations consultant in Boulder, Colo., decided to sell her half of the three-year old public relations firm she had started so that she could stay home to take care of her 4-year-old son and devote more time to her struggling marriage. Unfortunately, her sacrifice was in vain. Three months after selling out to her business partner, she and her husband decided to divorce. Even though they divided their assets equally, Bell has had to start all over in her career, working from home as an independent consultant.
    She now earns half of what she used to make in her old business, and has had to get used to living on a quarter of the income she enjoyed while she was married. She's also living with her son in the couple's old house, which she has been trying to sell since July. "It's become an albatross now," Bell says of her home. "It's a house filled with adult toys that are a representation of all of the money we accumulated in the marriage. It's full of stuff that I can't sell and I don't want anymore."

Harsh Reality for Some
When divorce hits the headlines it's usually those of the rich and powerful — like the recent splits of Jack Welch of General Electric or Sen. Jon Corzine of New Jersey — prompting court watchers to scrutinize how these by power brokers and their ex-wives divvy up their fortunes. But for people like Lisa Bell, mere mortals who don't have millions at their disposal, divorce can be the one of the most financially devastating events they will ever face. This is especially true for women, who are more likely than men to find themselves with financial difficulties after getting separated or divorced. According to the latest U.S. Census figures, 21 percent of recently divorced women were living below the poverty line, compared to only 9 percent of recently divorced men.
    How marital property gets distributed during a divorce differs from state to state. Most adhere to what is called an equitable distribution system, where a court divvys up the marital estate based on a number of factors, such a person's need or earning power. A small minority of nine states have community property rules, where marriage is considered a partnership and any property or assets acquired during the marriage are divided equally. Many see community property rules as a way to insure an equitable divorce.

Divorce Dollars: A State-by-State Guide
But the harsh reality is that even in these community property states, the lower wage earner usually suffers the most financially. That's because the spouse who earns more or has been able to keep their job maintains their earning power year after year. The spouse who decided to bow out of the workforce to maintain the home or family has to start from scratch in the working world, typically earning less.
    And though some women are making more money than their husbands these days, in most cases, the lower wage earner is often still the wife. "Most families are in a situation where they need the two incomes to maintain their lifestyle," says Myra Strober, labor economist and professor of education at Stanford University. "Now they're going to lose all of the economies of scale that couples have."

Separate, But Not Equal
   The plight of non-working spouses made big news in 1997 when Lorna Wendt, the ex-wife of former GE Capital chief executive Gary Wendt, contested her husband's offer to give her 10 percent of his assets, or around $11 million, at the end of their 32-year marriage. Wendt argued that even though she did not work, her role in the couple's marriage was one of an equal partner. She ultimately got $20 million, or half of her husband's hard assets. She later launched a campaign to get that figure increased to $35 million based on the value of her ex-husband's stock options and pension, but dropped her appeal last year after reaching a confidential agreement. Wendt's case took place in Connecticut, a state with equitable distribution rules. But experts say not even community property concepts are a panacea. Many couples are still left with lingering financial problems ranging anywhere from planning for their retirement to simply learning how to live on less.
    While there are no easy answers to the devastating economic impact of divorce, many say discussing finances before getting married, and even drawing up some sort of a pre-nuptial agreement or contract, might be the best way to prepare for the possibility of divorce. Wendt, for one, is now a crusader for promoting equal partnerships in marriage, founding The Institute for Equality in Marriage. The New York-based non-profit organization provides information and resources to help couples set up equal legal and financial partnerships before, during or after marriage. "It's a matter of respect and trust and realistically being able to sit down and say, 'We are legally sealing our union, now let's be smart enough to talk about what that means,'" says Courtney Knowles, vice president of communication for the institute. "People have to take charge even before their marriage gets rocky and discuss, how do we value each other?"

Men's Problem Too
   A whole new profession has sprung up from this marital uncertainty — the certified divorce planner. The profession has gained popularity over the past few years as a way for people to evaluate to financial impact of a divorce, something a lawyer may not do. Natalie Nelson, a financial divorce consultant in Boulder who worked with Lisa Bell, says she outlines exactly how long the proceeds from a potential settlement will last clients so that they can make suitable decisions about their futures. She doesn't make investment recommendations, but refers clients to others if they need services like investment or insurance planning. Nelson, who works with both individuals and couples, recently showed one woman going through mediation how a half million dollar settlement wouldn't last her until retirement — even on a tight budget. "I'm not looking just at the snapshot of the divorce itself but projecting many years into the future to let them know what the outcome of their settlement is going to look like for them," she says.
    Both Knowles and Nelson note that it's not just women who are seeking out help. Around 40 percent of the institute's Web site's readership is from men, and Nelson says she's had a number of male clients who are coping with how to deal with finances after a divorce. Says Nelson, "I wonder sometimes if people knew what divorce was going to cost them if they would try at all costs to avoid that outcome."

Researsh Shows Binge Drinking Damages Brains
Melinda T. Willis, ABC News- 4/17/2002

The animal study, published in the April issue of Alcoholism: Clinical & Experimental Research , finds that rats given large "bingeing" doses of alcohol every eight hours for four consecutive days experienced damage to their brains. The area of the brain responsible for smell was damaged after only two days of heavy drinking and other regions were damaged after four days.
    The new study counters a common belief that damage to brain cells occurs when the brain withdraws from long-term alcohol abuse, and not during alcohol consumption. "We found that in fact the damage appeared to be predominantly occurring in this binge drinking model during the intoxication," says Fulton Crews, director of the center for alcohol studies at the University of North Carolina in Chapel Hill, and co-author of the study. "This is a four-day model," added Crews. "If you went on a long weekend binge, you could do this."
    The amount of alcohol given to the rats was roughly the equivalent of 10 drinks in a single occasion for humans, twice the amount commonly defined as binge drinking for men (it's four or more drinks for women). Such binge drinking is relatively common — 15 percent of adults reported engaging in the practice at least once within the previous month, according to 1999 data from the National Center of Health Statistics.

The Damage of Drinking
A lot of what is known about human brains and alcohol has come from autopsy studies after someone dies following years of abuse. "It's under those conditions that most of our knowledge about the damaging effects of alcohol has occurred. But it doesn't mean that it hasn't occurred earlier," says John Crabbe, director of the Portland Alcohol Research Center at Oregon Health Sciences University.
    Some time ago, it was thought that brain damage associated with drinking was related to the poor nutritional intake of alcoholics — chronic drinking is related to a vitamin B1 deficiency and dementia. "There is a small component that is nutrition, but there is a larger component that is alcohol," adds Crews. Researchers have noted profound brain shrinkage associated with alcohol that can be seen on brain scans in living individuals, but the implications of this shrinkage are difficult to interpret. "When a person stops drinking — even if they have been drinking for a long time — frequently a good bit of that shrinkage recedes," explains Crabbe.

Detecting Damage Sooner
The same type of brain shrinkage is associated with aging, and there seems to be no straightforward relationship between the degree of shrinkage and cognitive decline. Experts say that is why animal models are helpful. They allow researchers to better understand the basic mechanisms that may be at work in humans. "We know humans have brain damage and we're trying to understand how that happens," explains Crews. "What these animal studies are doing are relating the brain damage to what we know about alcoholism in humans."
    Additionally, experts say that advances in brain imaging techniques will allow further understanding of what is happening to the living human brain because of alcohol consumption. "As [these imaging techniques] get better and better, we should be able to detect signs of changes in brain activity earlier and earlier," says Crabbe. "It's important to know how soon they start to develop."

For Children's Mental Health, Parents Give up Custody
Tim Higgins, Associated Press- 4/17/2002

JEFFERSON CITY, Mo. -- For two years, Donna Uhlmansiek tried to get her 10-year-old son admitted to a state mental hospital. Finally a health care worker suggested she go to court and give custody of the boy to the state. Uhlmansiek was horrified by the idea. Instead of giving up her son, she became part of a national movement to change state laws that encourage desperate parents unable to afford mental health care for their children to relinquish custody.
    A dozen states recently have changed their laws to allow children to more easily receive mental health treatment without their parents having to relinquish custody, according to the Bazelon Center for Mental Health Law in Washington. Other legislatures are considering such changes. In Missouri, legislation would prohibit courts from taking custody away from parents when the only issue is the child's need for mental health care. Legislation in Nebraska would allow the state health department to provide treatment without taking custody of a child.
    Middle-class families like the Uhlmansieks are most likely to relinquish custody of their children, experts say. That is because they earn too much to qualify for Medicaid but cannot afford doctors and hospitals when insurance falls short. The Uhlmansieks, whose son suffers from manic depression and is mildly retarded, had private insurance. But like most plans, it provided only 30 days of inpatient care. That had already run out. ''We had no place to go. We had exhausted every agency, every place that we were aware of. We were hopeless,'' Uhlmansiek recalled with a quavering voice. Ultimately, the Uhlmansieks decided they had no choice but to give up their son. But on the day they went to court two years ago, they met a juvenile court officer at the courthouse. And the officer pulled some strings to get the boy into a state mental hospital. Unlike the Uhlmansieks, Barbara French of Beulah, Mo., decided to relinquish custody of her teen-age granddaughter, who was later diagnosed as manic-depressive and suicidal. ''I had no choice in order to get her into treatment,'' French said. ''I just had to do it.''
    Parents who give up custody lose any say over their child's upbringing. And if the child is ultimately released from the mental hospital, the youngster can be placed in a foster home or another institution. Often, parents are encouraged to give up their children by hospital employees or social workers. ''People are floored when they hear this they have no idea that people are asked to relinquish custody of their kids in order to get services for their kids,'' said Darcy Gruttadaro, an attorney for the National Alliance for the Mentally Ill, based in Arlington, Va.
    A nationwide study by the organization found that about 20 percent of families with children with severe emotional problems turn their youngsters over to state custody. The Missouri Division of Family Services, for example, estimated that 500 children are in its custody solely because their families could not otherwise obtain mental health care.
    In many states, for parents to relinquish custody, a judge must decide that they are unable or unwilling to provide proper care. While the steps vary, typically this involves a parent petitioning the court; in some states, like Missouri, parents who take such a step also run the risk of being charged with abandonment or neglect. ''We love our child,'' Uhlmansiek said. ''I was so angry that me and my husband would have to be charged with a crime just to get our son the care he needed.''
    Children's advocates said state legislatures should provide more money to mental health efforts that would keep children at home. But with many states facing budget deficits, that is unlikely to happen. In Missouri, the state Department of Mental Health said it can afford to treat just 20 percent of the 53,000 children it estimates would qualify for services. ''No parent should have to make the decisions to give up their child just to get them the help that they need,'' said Uhlmansiek, who lives in suburban St. Louis. ''Things need to be changed.''
    On the Net:
Bazelon Center for Mental Health Law: http://www.bazelon.org
National Alliance for the Mentally Ill: http://www.nami.org

Doctor Says McDermott Mentally Ill
Michele Kurtz, Boston Globe- 4/17/2002

CAMBRIDGE - A psychologist who has studied the criminally insane told jurors yesterday that he believes Michael McDermott suffers from paranoid schizophrenia and is not faking mental illness, although he testified he wrestled with the question for more than a year. ''It is my opinion that no, he is not malingering, that this is a genuine, serious, and terrible mental illness,'' said Dr. Ronald Ebert, who has seen McDermott 10 times since he shot to death seven co-workers at Edgewater Technology on the day after Christmas in 2000. Ebert, testifying for the defense, said he believes that McDermott, 43, was so ill at the time of the killings that he didn't realize what he was doing was wrong and is therefore not criminally responsible for the shootings. But under cross-examination, Ebert acknowledged that McDermott is smart and clever enough to create a ''psychic alibi'' -- as the prosecutor put it -- for opening fire on his Wakefield colleagues. ''I think he's smarter, probably, than anyone in this courtroom,'' Ebert testified.
    McDermott has testified that St. Michael the Archangel visited him on Dec. 14, 2000, and told him to travel back in time and kill Adolf Hitler and six Nazi generals. Speaking lucidly and often glibly, he told jurors that he believes he died in a Berlin police station and is currently in purgatory. Prosecutors contend that McDermott made up the scenario using his keen intellect and years of research into mental illness, and that he actually opened fire because he was angry at the company for planning to seize his wages to pay back taxes.
    Ebert, who worked at Bridgewater State Hospital for eight years evaluating and treating dangerous, mentally ill men, said he was suspicious that McDermott might have concocted the bizarre story to avoid prison. For one thing, he said, McDermott's elaborate tale was unusual, even for people with schizophrenia, a major mental illness characterized by hallucinations and delusions. During their meetings in the Middlesex County jail, Ebert said McDermott described ''a life of many, many disappointments'' and told him of his suicide attempts and various hospitalizations. Ebert also examined McDermott's past medical records.
    Although no doctors had diagnosed McDermott with schizophrenia, Ebert said there was evidence that he experienced symptoms of the disease decades ago. Some incidents suggested that McDermott was delusional and paranoid, he said. For example, McDermott has long believed that he suffered radiation exposure while working at a nuclear power plant in Maine, although medical tests did not indicate that, Ebert said. More than 20 years ago, McDermott complained of experiencing visual distortions, and he told Ebert that voices had told him to steal and hoard glass lab equipment from his company in the 1990s.
    Under cross-examination by Middlesex District Attorney Martha Coakley, Ebert acknowledged that it's extremely difficult to detect whether someone is faking psychosis, as he wrote in his book ''Violence Prediction.'' To be sure he was right in this case, Ebert said that less than a month ago he gave McDermott a test to detect if he was pretending. The test was developed by the author of a book McDermott had bought on how to fake mental illness. Ebert said the results supported his conclusion that McDermott was not faking. But under questioning by Coakley, he said that McDermott's high score on one part of the test -- on exhibiting rare symptoms -- was a red flag and suggested McDermott was making things up. But Ebert said that was only one section of the test, and that the test overall and other evidence convinced him McDermott was not faking.
    Jurors also heard from Rosemary Martinez, McDermott's mother. She testified that she called her son the morning of Dec. 26, 2000, and wished him a happy Boxing Day, an utterance that McDermott said was the last sign he'd known he would receive before it was time to start his ''mission.'' Martinez testified on cross-examination that McDermott was a highly intelligent child and a ''wonderful, wonderful'' actor in his teenage years.
    Assistant District Attorney Thomas O'Reilly asked Martinez whether McDermott signs ''I love you'' to her in sign language when he enters the courtroom each day in shackles and holding a Bible. She said he does, and demonstrated that she returns the message by folding her hand into a fist, putting it over her heart, and extending her index and pinky fingers. ''He gives those signals while he's emotionless in court so he won't create a [media] story, right?'' O'Reilly asked. ''Yes,'' Martinez answered. McDermott testified last week that his parents sitting in the courtroom are not real, but ''constructs'' of his parents and that he talks to them so as not to be ''rude.'' Superior Court Judge R. Malcolm Graham told jurors to prepare to be sequestered once they begin deliberations. The case could go to the jury by the end of the week.

Psychologist Says Prozac May Have Contributed to Gunman's Rage
Denise Lavoie, Associated Press- 4/17/2002

CAMBRIDGE, Mass. --A man on trial for killing seven co-workers tripled his dosage of Prozac before the shootings, a move that may have heightened his rage and sparked the shooting spree, a defense psychiatrist testified Wednesday. Dr. Anthony Joseph said Michael McDermott suffers from paranoid schizophrenia and other mental disorders that made him unable to understand that what he was doing was wrong when he opened fire at Edgewater Technology on Dec. 26, 2000.
    Joseph said McDermott told him that he had increased his dosage of Prozac by Dec. 1, first from 70 milligrams per day to 140 milligrams, and then to 210 milligrams. Joseph said McDermott increased the dosage without his doctor's permission or advice. ''It's very possible that Prozac is the final piece of the puzzle that explains the level of rage and anger that allowed the killings to occur,'' Joseph said. Although Prozac acts as an antidepressant, potential side effects include restlessness, agitation, psychosis, rage, anger and violence. Joseph acknowledged he could not say to ''a reasonable degree of medical certainty'' what effect the increased dosage had on McDermott. On Thursday, prosecutors planned to cross-examine Joseph. Prosecutors also plan to call witnesses to support their theory that McDermott concocted an elaborate tale to make himself look insane to the jury.

Economic Loss From Smoking at $7 a Pack
Erin McClam, Associated Press- 4/17/2002

ATLANTA -- Each pack of cigarettes sold in the United States costs the nation $7 in medical care and lost productivity, the government said today. The study by the Centers for Disease Control and Prevention put the nation's total cost of smoking at $3,391 a year for every smoker, or $157.7 billion. Health experts had previously estimated $96 billion. Americans buy about 22 billion packs of cigarettes annually. The CDC study is the first to establish a per-pack cost to the nation. The agency estimated the nation's smoking-related medical costs at $3.45 per pack, and said job productivity lost because of premature death from smoking amounted to $3.73 per pack, for a total of $7.18. The average cost of a pack of cigarettes in 1999 was $2.92.
    "There's a big difference in the cost to society and what society is getting back in tax," said the CDC's Dr. Terry Pechacek. "We believe society is bearing a burden for the individual behavioral choices of the smokers." The CDC said it analyzed expenses, both personal and for the health care industry, and used national medical surveys to calculate the costs to the nation.
    The agency also reported that smoking results in about 440,000 deaths a year in the United States, up from the government's previous figure of 430,000, established in the early 1990s. The new study was conducted from 1995 to 1999. "The fact that nearly half a million Americans lose their lives each year because of smoking-related illnesses is a significant public health tragedy," said Dr. David Fleming, the CDC's acting director.
    A spokesman for tobacco giant Brown & Williamson objected that the study presents the figures in a vacuum, without comparing smoking to the financial burdens other people -- nonsmokers with diabetes, for example -- place on society. "What does that number mean?" spokesman Mark Smith said. "It doesn't mean anything. It's bordering on meaningless." Representatives from the nation's two other leading tobacco companies -- Philip Morris and R.J. Reynolds -- did not immediately return calls for comment.
    Among other findings:
-- Smoking causes an average man to lose more than 13 years of life, and an average woman to lose 14.5 years.
-- Smoking during pregnancy causes about 1,000 infant deaths each year.
-- Lung cancer causes the most deaths among smokers, following by heart disease and lung disease.
-- Men account for about 60 percent of smoking deaths -- 264,000 a year, compared with 178,000 deaths among women.

Beyond the Nicotine Patch
Sally Squires, Detroit News- 4/17/2002

When it comes to quitting cigarettes, Denise Scott knows a lot about failure. "Every time I put out a cigarette, I wanted to quit," says Scott, 42, of Chesterfield Township. "Every morning when I would wake up hacking, reaching for my cigarettes, I wanted to quit." She started smoking around age 13, became a regular puffer when she was 18 and eventually graduated to a pack-a-day habit. Scott quit twice cold turkey when she was pregnant, but after the birth of each child, she lit up again. Last year, Scott went to her doctor to discuss methods to assist in quitting. She opted for the patch, which, Scott says, gave her the bridge she needed, She has been smoke-free since Sept. 1.
    About 40 percent of America's 50 million smokers will try to kick the habit at least once this year, according to the federal Centers for Disease Control and Prevention. On each attempt, fewer than one in 10 will succeed. However, nicotine addiction researchers say those failures pave the road for breaking dependence on tobacco -- something that about half of smokers ultimately achieve, according to federal treatment guidelines. "Most people have to try to quit probably five to seven times before they succeed," says John Hughes, professor of psychiatry at the University of Vermont. "It's just like swimming -- it's important to keep jumping in the water to learn."
    And as experts like to note, there has never been so many scientifically validated options to help smokers reduce the pangs of nicotine withdrawal and the craving for cigarettes. Ten years ago, "all we had to offer was going cold turkey or nicotine gum," says Michael C. Fiore, chairman of a federal panel that issued treatment guidelines two years ago calling for nearly every smoker who wanted to quit to use medications to support their efforts. Today, there are seven drug treatment choices, as well as many smoking-cessation programs and individual counseling services that also boost chances that smokers will manage to quit.

New strategies
Four safe and proven nicotine replacement methods -- gum, a patch that delivers nicotine through the skin, an inhaler that mimics the effect of smoking and a spray that provides a quick burst of nicotine to nasal passages -- can deliver gradually declining doses to take the edge off cravings and withdrawal. They have minimal side effects, a low risk of addiction and are free of the nearly 4,000 harmful substances that cigarette smoke delivers. An antidepressant medication -- bupropion, marketed for depression under the brand name Wellbutrin and for smoking cessation as Zyban -- can also help break cigarette addiction, though the scientific process by which this occurs is still not understood. There have been reports of serious adverse effects, including some deaths, from Zyban in Europe. "It's unclear if the events are related to the medication," Hughes says. Two other options for especially difficult cases of smoking addiction are the blood pressure medication clonidine and the antidepressant nortriptyline. While the evidence of their value is not as extensive as that for nicotine replacement drugs, a government panel advised recently that these medications be tried if other drugs have failed. (Neither is approved for this use by the Food and Drug Administration.)
    Trouble is, a lot of smokers try to quit the wrong way. Since smoking is often viewed as a weakness, many smokers tend to tough it out, going cold turkey. Or they mistakenly use minimal amounts of the nicotine replacement drugs and other medications proven to help assuage the strong physiological symptoms of withdrawal. "That is why there is such a high relapse rate," explains David Sachs, clinical associate professor of pulmonary and critical-care medicine at Stanford University School of Medicine in California. "It's like killing all four engines on a Boeing 747 where you're 2,000 feet above the runway. You crash and burn and then people start beating up on themselves."
    That describes Scott. She suffered through cold turkey only to pick up cigarettes again. That changed with the patch. "When I was on the patch, I didn't have the need to smoke, but it was the habit I had to break," she says. "You know, drinking coffee and having a cigarette, watching TV and having a cigarette. That's what I had to quit." Not to say that nicotine addiction is all in the mind, but that is where part of the craving lies.
    "Most people have a very pleasurable association with smoking," says Rena Greenberg, a certified hypnotist, who has worked with hundreds of people through several Metro Detroit hospital systems. "For most smokers, it is the only time they relax. We retrain the subconscious association from pleasurable to painful. What people should remember is that not any one method works for everyone. For some people, the patch or gum will work. We provide behavior modification." Greenberg's Wellness Seminars report a one-year success rate is 28 percent.

Nicotine and the body
Adult smokers go through an average of a pack each day. At 20 cigarettes per pack and 10 puffs per cigarette, that's 200 nicotine hits a day right to the brain, making smoking "one of the world's most intense habits," Hughes says. Chemically similar to naturally occurring neurotransmitters or chemical messengers, nicotine displaces some brain chemicals. Just 10 days of smoking triples the number of entry points -- receptors -- that allow nicotine to get inside brain cells, Sachs says. There, nicotine acts on the pleasure-reward pathway by raising levels of four key neurochemicals that affect alertness, energy and mood -- dopamine, norepinephrine, beta endorphins and serotonin. (Newer antidepressant medications target levels of these same brain chemicals.) "The bottom line is that nicotine has a lot of very beneficial effects on how we feel and think," Sachs says.
    That's why the development of effective nicotine replacement drugs has finally given an edge to smokers who want to quit. Using one or more of these medications boosts success rates to about 25 percent, found treatment guidelines issued in 2000 by the Agency for Healthcare Research and Quality. Evidence suggests they could go higher if more intensive treatment and greater support were applied. Close monitoring of withdrawal symptoms and tailoring nicotine replacement therapy to the individual has produced success rates of up to 50 percent at some of the best smoking-cessation programs.
    At Mayo's Nicotine Dependence Center, for instance, smokers pay $3,300 each to check into an intensive, weeklong residential smoking-cessation program. They undergo blood testing for cotinine, a marker of nicotine byproducts; the tests are used to help adjust treatment individually for withdrawal symptoms and cravings. The program includes daily group and individual therapy, stress reduction, nutrition and diet information, supervised exercise and a 12-step program similar to Alcoholics Anonymous. About 700 smokers have gone through the decade-old program, which attracts long-term older smokers -- average age 53 compared with early 40s for other programs -- who have tried to quit on numerous occasions. Eighty percent of the participants are experiencing tobacco-related illnesses such as emphysema or heart disease. Yet, one year after treatment -- the longest follow-up data available -- about 45 percent of participants remain smoke-free, according to Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minn.

What approach works best?
In the community at large, however, research suggests smokers and some physicians are confused about what approach to use. Science can't say with certainty which smoker will benefit most from which treatment, but there are hints. "Men seem to do better (than women) with nicotine gum and the patches," says Neil Grunberg, professor of psychology and neuroscience at the Uniformed Services University of the Health Sciences in Bethesda, Md. Studies suggest bupropion works equally well in men and women and is especially helpful for smokers with a past history of depression, according to Fiore. The 2000 treatment guidelines note gum and bupropion seem to help prevent weight gain. Those who have experienced severe withdrawal symptoms in previous attempts to quit may do better on the patch; studies suggest that smokers who suffer severe cravings seem to be helped by the high-speed nicotine delivery of the gum, the inhaler or the nasal spray.
    Yet, all too often, tobacco-addiction experts find smokers go cold turkey -- an almost-certain program for failure. Or they don't follow directions and use too little of the medications to help them succeed, perhaps because the treatment can cost $4 to $18 a day -- compared with $3.50 for a pack-a-day habit. Not using enough replacement medication can sabotage the most dedicated attempts to quit. At Stanford, Sachs and his colleagues monitored blood levels of nicotine as smokers quit and compared them with the eventual rates of success. When nicotine levels dropped too precipitously to 50 percent or less of what they had been while participants were smoking, success rates were no better than the 5 to 8 percent seen with a placebo, about equivalent to going cold turkey.
    Another mistake smokers make is thinking of nicotine replacement as a magic bullet. "None of these products is magic," says Milana Fayvusovich, a Beaumont Hospital pharmacist who helps run Beaumont's smoking cessation program. "For people who have quit for 10 years, the craving could still be there." The federal treatment guidelines found that only the combination approach -- proper doses of medication along with professional and/or social support -- can consistently push the success rates to about 30 percent.
    For those trying to quit, there's no safe way to light up a single cigarette, which is why the current treatment guidelines advise abstinence. Some nicotine replacement medications, such as the patch, could contribute to toxic levels of nicotine if they are combined with smoking and lead to nausea, blood pressure problems and other health effects. But worse, even one cigarette can send a smoker down a slippery slope toward re-addiction.
    "There's never a point where there is an absolute guarantee that someone has quit smoking," says Harry Lando, professor of epidemiology at the University of Minnesota's School of Public Health and a member of the federal committee that drafted the treatment guidelines. It is true, however, that the longer abstinence is achieved, the better the chance that it will be permanent. Studies show that smokers who quit for a year have an 85 percent chance of maintaining abstinence, Lando says. Those who make it five years have a 97 percent chance of continued success. Even so-called "failures" -- people who quit for days or weeks but go back to smoking -- stand a good chance of succeeding ultimately. Studies show that being able to stay off cigarettes for a week is strongly linked eventually to long-term quitting. "The message is: Keep trying," Hughes says. "A lot of people give up too soon. The No. 1 message is that there is a lot of help out there now."

Resources for stopping smoking
Need assistance to quit smoking? Ask your family doctor about options, which could include Zyban, a nasal spray or inhaler. Also, many hospitals run smoking-cessation programs. Here is where you can find some local programs.
* William Beaumont Hospital, (800) 633-7377.
* Karmanos Cancer Institute, (800) KARMANOS (527-6266).
* St. John Health System, (800) 848-2822.
* University of Michigan, (734) 936-5988.
* Henry Ford Health System, a phone-based program, (888) 427-7587.
* Oakwood Hospital, (800) 543-9355.
* Hypnosis. Wellness Seminars, run by Rena Greenberg, (800) 848-2822.

Free help
Free smoking-cessation materials are available from a number of organizations including:
* Agency for Healthcare Research and Quality, (800) 358-9295, www.ahcpr.gov/consumer/helpsmok.htm.
* American Cancer Society, 1599 Clifton NE, Atlanta, GA 30329; (404) 320-3333.
* American Heart Association, 7272 Greenville, Dallas, TX 75231; (800) AHA-USA1.
* American Lung Association, 1740 Broadway, 14th floor, New York, NY 10019; (212) 315-8700.
* Centers for Disease Control and Prevention, Office of Smoking and Health, (800) 232-1311, www.cdc.gov/tobacco/.
* National Cancer Institute, (800) 4-CANCER; http://cis.nci.nih.gov/fact/8_13.htm
* U.S. Public Health Service, www.surgeongeneral.gov/tobacco/default.htm   (information available in English and Spanish).

For pregnant smokers
* American College of Obstetricians and Gynecologists, 409 12th St. SW, Washington, D.C. 20024; (202) 638-5577.
* American Legacy Foundation (has cancer information specialists available 24 hours a day), (866) 66-START.

Congressman Urges Autism Research
Janelle Carter, Associated Press- 4/18/2002

WASHINGTON -- Research funding for autism lags behind other diseases even as the number of children diagnosed with the condition is increasing, a congressman complained Thursday. "Funding into basic and clinical research into autism needs to grow," said Rep. Dan Burton, R-Ind., chairman of the House Government Reform Committee. Burton's grandson, Christopher, is autistic. "We have an epidemic on our hands and we in Congress need to make sure the NIH (National Institutes of Health) and CDC (Centers for Disease Control and Prevention) treat this condition like an epidemic," Burton said.
    Autism is a neuro-biological disorder that typically appears during the first three years of life. Children and adults with autism typically have difficulties in verbal and nonverbal communication and social interactions. The disorder makes it hard to communicate with others and relate to the outside world, and in some cases, those with autism can exhibit aggressive behavior. Officials don't know the exact prevalence of autism but estimate that it affects anywhere from one in 500 to one in 1,000 people in the United States, according to a February report to Congress by the National Institute of Mental Health. Ten years ago, autism was thought to affect one in 10,000 individuals in the United States.
    Burton said the CDC is spending $11.3 million on autism this year and $10.2 million next year. Meanwhile, the agency will spend $932 million on AIDS this year and over $62 million on diabetes. Similarly, the National Institutes of Health, which has a $27 billion budget this year, is spending $56 million on autism and $2.2 billion on AIDS research. Another $688 million is being used for diabetes research.
    Stephen Foote, a director at the National Institute of Mental Health, said NIH funding for autism had grown from $22 million in 1997. "NIH has made substantial progress . . . in further expanding and intensifying our autism research activities," he said. Still, The Autism Society of America wants NIH research funding to increase to $500 million a year. The organization estimates that the disorder is increasing at a rate of 10 percent to 17 percent a year, "faster than any other disability or disease," said Lee Grossman, the society's president.
    On the Net:
http://www.autism-society.org
http://www.house.gov/reform/

Child Abuse Cases Rise in 2000
Laura Meckler, Associated Press- 4/19/2002

WASHINGTON -- Cases of child abuse and neglect rose in 2000 for the first time in seven years, the government said Friday, with nearly 900,000 victims. Officials said they were uncertain whether the small increase would mark the end of a downward trend. Whether or not it does, the number is too high, said Wade Horn, assistant secretary for children and families at the Department of Health and Human Services. "Behind these statistics are real children who are suffering real physical and emotional pain," he said in a statement. "We are working hard to reduce these numbers, and we must rededicate ourselves to successful prevention efforts."
    About 1,200 children died of abuse or neglect in 2000, a small increase from 1999 that officials believe is due to improved reporting. Confirmed maltreatment cases peaked in 1993, with 15.3 per 1,000 children. The rate fell for six straight years, hitting 11.8 per thousand in 1999. In 2000, there were 12.2 cases per thousand, or a total of about 879,000, HHS said.
    Child abuse typically increases in bad economic times, said Ching-Tung Wang, a researcher at Prevent Child Abuse America. "People are facing more economic stress because, as we know, poverty is one of the highest risk factors for maltreating kids," she said. But she said that it won't be clear until 2001 data is available whether there's a real rise.
    Child protective service agencies across the country received about 3 million referrals in 2000, according to data reported to the federal government. More than two in three of them were not substantiated after investigation. Of those that were confirmed, 62 percent suffered neglect, 19 percent were physically abused, 10 percent were sexually abused and 8 percent were psychologically maltreated. Consistent with previous years, 84 percent of victims were abused by a parent.

Michigan HMOs Report Loss of $1.1 Million in 2001
Associated Press, 4/20/2002

LANSING, Mich. -- A struggling health maintenance organization in Michigan lowered the industry's overall profits last year to a $1.1 million loss, the state's insurance office said Friday. OmniCare Health Plan, which is currently in court-ordered rehabilitation, lost $50 million last year, the Office of Financial and Insurance Services said in its year-end report. Excluding Omnicare, the HMO industry in Michigan reported a $48.8 million profit in 2001, the report said. The industry reported less last year than the $51.7 million profit it experienced in 2000. Seventeen of the 27 HMOs that reported their financial information to the Office of Financial and Insurance Services reported a profit for 2001, the report said. Fifteen reported a drop, it said. Overall, the HMO's industry reported a $30.6 million improvement in capital and surplus. HMOs have the second largest share of the health insurance market in Michigan behind Blue Cross Blue Shield, Michigan Insurance Commissioner Frank Fitzgerald said. "The 2001 statistics continue to show that the HMO industry is safe and sound," he said.
    Twenty-three HMOs said they provided services for Medicaid recipients in 2001, reporting an overall income of $40.2 million. Three of the 23 reported a loss of $3 million in the Medicaid business. Four of the seven HMOs that reported amounts for Medicare coverage lost $10.8 million and three reported a $4.5 million profit. Michigan's HMOs spent $353 million on prescription drugs last year, which is 6.5 percent of their total medical expenses, according to the insurance agency's report. There are 29 HMOs in Michigan, but Family Health Plan hadn't yet filed its annual report and Omnicare didn't have to turn over its year-end numbers until its court hearing next week, the state insurance office said.
    On the Net:
Michigan Office of Financial and Insurance Services, http://www.cis.state.mi.us/ofis

Psychiatrists Say McDermott's Faking
Michele Kurtz, Boston Globe, 4/20/2002

CAMBRIDGE - An angry Michael McDermott carefully plotted to murder his co-workers and dreamed up a wild story about killing Hitler before he ever pulled the trigger, a forensic psychiatrist testified yesterday. Dr. Malcolm D. Rogers, testifying for the prosecution, told a jury poised to begin deliberations on Monday that McDermott is depressed and has a personality disorder but is faking schizophrenia to try to avoid going to prison for the murders of seven Wakefield co-workers on the day after Christmas in 2000. ''He was playing out a story,'' Rogers, a veteran psychiatrist, testified in Middlesex Superior Court. ''The description in his apparent delusion of going back in time, reversing history, being particularly clever in a highly organized scenario ... is reminiscent to me of a role-playing game.'' Another psychiatrist hired by the prosecution, Dr. Michael Annunziata, said of McDermott, ''Absolutely, he's faking.''
    McDermott's lawyer, Kevin Reddington, tried to portray both Annunziata and Rogers as being in the prosecutors' pockets. At one point he rattled off a list of criminal cases in which Annunziata worked for prosecutors, dramatically slamming transcripts and reports from each case onto a lectern. Suggesting Annunziata failed to consider ''important'' pieces of information about McDermott's history, Reddington asked the psychiatrist whether he had reviewed an apparent suicide letter McDermott wrote before he cut his wrists in 1987 amid a dispute at work and a bad breakup. Police pulled the letter - addressed to ''my dearest family'' - off McDermott's computer after the killings. Annunziata, who had testified that he thought McDermott, 43, had attempted ''suicide gestures'' to get attention, said he didn't recall the note. ''One of the strange qualities of mental illness is being conscious of abnormal behavior, but being unable to do anything about it, only watch terrified, as they grow,'' the note read. ''Crying for help, but being unable to ask.'' Another section of the note read, ''These past few months have been bad. Despondency can be a self-fulfilling prophecy. In all things, not just death, people sometimes sense when another isn't going to make it. Like school boys, they gather 'round to watch and cheer as he falls. Every one sure to get in his kick or to throw his stone.''
    McDermott's fate hinges on whether jurors will believe his attorney's contention: that he was so mentally ill at the time of the killings that he didn't know what he was doing was wrong or that he was unable to stop himself. In weighing that issue, jurors will have to assess McDermott's testimony and sort through days of conflicting opinions from two camps of medical experts.
    On one side are the defense psychiatrists, who say McDermott, of Haverhill, suffers from paranoid schizophrenia, which made him lose touch with reality and believe he was traveling back in time to kill Hitler and six Nazi generals in order to accomplish a holy ''mission.'' They say he has a history of hallucinations that other doctors failed to diagnose as schizophrenic, and that a triple dose of Prozac may have launched the deadly rampage.
    Psychiatrists who testified for the prosecution acknowledge that McDermott has mental problems, but they say he is pretending to hear voices and to believe he's now in purgatory - a scenario he's conjured up with the help of years of research on mental illness. They describe McDermott as a stubborn and angry man who often spurned authority and grew enraged that Edgewater Technology planned to seize part of his wages for a debt the Internal Revenue Service said he owed.
    Rogers, who interviewed McDermott three times in jail, said McDermott's delusion is too organized to be genuine and that his statement, ''I don't speak German,'' to police was another planned part of the scenario. Though McDermott sits passively at the defense table appearing to read a worn Bible, Rogers said he's given signs that he's carefully following the proceedings. ''He turns to the jury,'' Rogers said. ''He describes his parents as `constructs' and yet sends signs to his mother.'' Rogers also said most psychotics exhibit signs of deterioration in the weeks leading up to a major psychotic event. But McDermott's work performance had not dropped.
    Reddington, flipping through a small black filing box, asked Rogers whether he knew that McDermott had kept his canceled checks in numerical order in that box, but had apparently stopped doing that after 1997. Police also found in his Haverhill apartment stacks of unopened mail and moving boxes that had not been unpacked. ''Does that tell you whether he was deteriorating?'' Reddington asked. ''It tells me he didn't open his mail,'' Rogers said.