Is There More Autism? Or Just a New Definition?
Lindsey Tanner, Associated Press- 3/1/2003

CHICAGO -- Mention autism to parents, doctors and scientists these days, and among an earful of different theories will emerge a common nod of agreement: The perplexing condition is not nearly as rare as once was thought. As recently as a decade ago it was estimated that only about 4 per 10,000 children were affected. Research now suggests the rate may be at least 10 times higher. The numbers have fueled debates over whether there's been a true surge of cases and whether environment or genetics could be the cause. Some parents and research advocates blame vaccines despite recent evidence to the contrary. But many mainstream scientists point to two much less worrisome explanations: The definition for autism has changed and schools now offer more educational services to autistic children.
    In 1991, the U.S. Department of Education made autism a new, separate category for special education services offered at public schools. Those services tend to be broader and more intensive than for other disorders, including mental retardation. There's evidence that the 1991 change prompted what some call ''diagnostic substitution,'' said Dr. Fred Volkmar, a Yale University autism researcher. ''Autism is kind of a fashionable diagnosis,'' Volkmar said. ''Everybody's interested in getting better services.'' Statistics seem to back up the theory. Department of Education figures show that the number of children getting services for mental retardation fell from 553,262 in 1991-92 to 532,362 in 1992-93. During those same years the number of children getting services for autism swelled from 5,415 to 15,580.
    The change in school services and the definition, along with research showing that early intervention could help, raised awareness of the condition. Autism used to be thought of as ''the kid who sits in a corner watching the record player go around and around. Everybody said that's what autistic is and anything else is not,'' said Chicago pediatrician Dr. Joel Schwab. Schwab said that like many doctors, he may have inadvertently diagnosed autistic youngsters a decade ago as being mentally retarded, or with nondescript behavior problems. Now, autism is increasingly recognized as ''being more than just the classic picture,'' said Schwab.
    Molecular biologist Andy Shih, director of research and programs for the National Alliance for Autism Research, says that whether or not there's been a surge in cases, ''what is clear is that autism is a serious public health issue. ''With potentially 1 million Americans afflicted with this disorder,'' Shih said, ''it is no longer something that is rare or seldom seen.''
    The impact has reached far outside the medical realm. Many schools are struggling to provide enough services to affected children, funding for research into causes has grown, and lawsuits blaming vaccines are proliferating. ''There's just so many kids who have been affected, it's hard to find somebody who doesn't know somebody who has a kid with autism,'' said Liz Birt of Wilmette, Ill., whose 9-year-old son, Matthew, is autistic. Within seven blocks of their suburban Chicago home, five other children also are afflicted. ''It's just rampant,'' Birt said.
    Autism even ended up in a debate over a last-minute provision attached to Homeland Security legislation enacted last fall. The provision, aimed at protecting drug makers from lawsuits over vaccine-related injuries, prompted vocal protests in Washington in January by parents who think childhood vaccines cause autism.
    Much has been learned about autism in the past half century. The once prevailing ''refrigerator mother'' theory suggesting cold, aloof mothers caused autism was long ago thrown out as scientific advances favored a biological cause. But many key questions remain. Researchers don't know if a single gene or many are involved, or possibly different ones in different cases. Some think environmental factors might trigger the disease in genetically susceptible people. Potentially plausible but unproven triggers range from illness during pregnancy to soil toxins, electromagnetic waves and even vaccines, though strong evidence so far suggests the shots are safe. ''There's so many things that it could be,'' said Dr. Robert Byrd of the University of California, Davis. A recent study suggested autism cases in California surged nearly 300 percent over 10 years, and Davis researchers are trying to pinpoint why. The clamor over causes and numbers has prompted a call for the American Medical Association to investigate.
    Autism has raised deep questions ever since psychiatrist Leo Kanner first described it as a distinct developmental disorder in the early 1940s, after observing several curiously afflicted children in Baltimore. It remains ''a particularly challenging mystery,'' said Steve Foote, director of neuroscience and basic behavioral science at the National Institute of Mental Health. Kanner described what is now known as classic autism children with severe impairments in language and communication, who may appear deaf, sometimes don't speak, show little eye contact and appear more interested in interacting with objects than with humans. Repetitive behaviors such as rhythmic finger tapping or ball-rolling are common. Sometimes symptoms show up in children who previously appeared to be developing normally; some call this regressive autism. It was initially linked to schizophrenia until 1980 when it first appeared as a separate disorder called ''infantile autism'' in the American Psychiatric Association's manual defining mental disorders. It has been redefined twice in updates of the manual.
    Autism is not curable but can be helped with behavioral treatment and sometimes medication. ''People have a much better idea about the diversity of autism. There's such a range of both severity ... language handicap and mental retardation,'' said prominent autism researcher Catherine Lord. ''That has changed perspective on autism both in terms of figuring out who needs services and also the prognosis for people in the mild range,'' said Lord, director of the University of Michigan's Autism and Communications Disorders Center. Not all children with autism are mentally retarded but most need special services.
    Kathy Gould, project director for an Illinois program that trains teachers and parents how to work with autistic children, said demand has increased significantly in the past five years. ''Every day, more and more people in more and more district schools are saying these kids are coming in and we don't know what to do with them,'' Gould said. ''Parent workshops have gone from three a year to 15 a year. Parents are crying out for additional help,'' she said.
    Liz Birt is among them. Her son, Matthew, developed normally until he was 15 months old, when he could count to 10 and say about 30 words. He developed autism symptoms gradually after receiving two childhood vaccinations on the same day, Birt said. He stopped talking, acted as if he was deaf, spun in circles, stared at lights and shunned his family. At 9, Matthew Birt is still profoundly affected and his mother worries that as he grows into adulthood, no services will be available. ''Somebody's got to pay attention to this,'' Birt said. ''We're talking about hundreds of thousands of children who are going to be a big drain on the economy.'' An attorney, she says she'd like to sue vaccine makers but can't because of legal restrictions against suits filed more than three years after a child's first symptoms.
    Vaccine foes like Birt point to a 1998 British study linking autism with the measles-mumps-rubella vaccine. There's been a subsequent backlash against vaccines in England and recent measles outbreaks. The Institute of Medicine reviewed the issue and in 2001 said there was no proof that autism is caused by the MMR vaccine or by the mercury-containing preservative thimerosal that was present in some vaccines. Vaccine foes note the IOM report said a link between thimerosal and an increased risk of neurodevelopmental disorders is ''medically plausible.''
    Dr. Neal Halsey, an influential vaccine proponent from Johns Hopkins University, agrees that thimerosal could theoretically be linked with subtle developmental problems including delayed speech, ''but the available data show no evidence of an association with autism.'' ''Ongoing studies should answer the question about other neurodevelopmental problems in about one year,'' Halsey said. After evidence in 1999 suggested that the combined amount of thimerosal in vaccines could expose children to mercury exceeding recommended maximum levels, Halsey worked with the American Academy of Pediatrics and the U.S. Public Health Service in urging vaccine makers to discontinue thimerosal use. Now, no vaccines given to children under 6 months of age contain thimerosal, he said. ''I do not, and never did, believe that any vaccine causes autism,'' Halsey said. Ironically, the opposite may be true, he said, since women who develop German measles (rubella) early in pregnancy face an increased risk of having an autistic child.
    Not all researchers are convinced that there is no autism link, and the National Institutes of Health is funding studies to investigate. NIH funding for autism research has grown along with the number of cases, from $22 million in fiscal year 1997 to $73.85 million last year, Foote said. Recent research has led to important discoveries, including evidence that intensive behavioral training starting as early as infancy can substantially improve symptoms in some autistic children.
    Volkmar, at Yale, and colleagues have found that while healthy babies learn social interaction by focusing their gaze on people's eyes, autistic children focus more on mouths. This could help parents and doctors identify affected children earlier and get them early intervention, Volkmar said.
    Other scientists are searching for genes and other ''biomarkers'' that might make autism as easy to diagnose as a simple blood test. For now, doctors still rely on behavior to diagnose autism. Studies of identical twins, whose genetic makeup is nearly identical, have shown that if one has autism, the other faces at least a 90 percent chance of having severe social impairment, said Dr. Edwin Cook of the University of Chicago. But pinpointing which combination of genes are involved could take years, he said. ''There's just too much we don't know,'' Cook said.
    On the Net:
NIH: http://www.ninds.nih.gov/healthandmedical/pubs/autism.htm
NIH research: http://www.nichd.nih.gov/publications/pubs/autism/mmr/sub4.htm
National Alliance for Autism Research: http://www.naar.org

Massachusetts Supreme Court to Rule on Gay Marriage
Kathleen Burge, Boston Globe, 3/2/2003

When the Supreme Judicial Court meets on Tuesday, it will consider the most politically charged matrimonial issue since the state lifted the ban on interracial marriage more than 150 years ago: whether to legalize marriage between same-sex partners. It is the culmination of a legal battle that began when seven same-sex couples applied for marriage licenses and were denied, touching off a case that puts Massachusetts in the forefront of the international legal debate.
    If the SJC agrees with the plaintiffs, Massachusetts could become the first state in the nation to sanction same-sex marriage. As a result, the justices have been flooded with opinions from hundreds of groups that have filed 26 advisory briefs, from state attorneys general to international human rights organizations and law professors from as far away as Australia. Religious groups have weighed in on both sides, with most urging the court not to change the marriage laws. Catholic, Protestant fundamentalist, and Orthodox Jewish groups argue that homosexual unions are immoral and should not be sanctioned. The Unitarian Universalist Association, meanwhile, endorses the legalization of same-sex marriages.
    ''It is momentous,'' said attorney Mary Bonauto of Gay and Lesbian Advocates and Defenders, who is arguing the case for the seven couples. ''March 4 will be a very important day for lots of families across this commonwealth who right now are excluded from many protections that they need, for themselves and for their children.''
    The SJC is not the first state supreme court to consider same-sex marriage. After a similar case in Vermont, that state in 2000 created civil unions, domestic partnerships that bring many of the benefits of marriage. But they are not legally equal to marriage, nor are they recognized outside of Vermont. Courts in Hawaii and Alaska approved gay marriage, but legislatures in those states subsequently passed constitutional amendments limiting marriage to men and women -- a tactic that could be tried here if the SJC rules for the seven couples. A New Jersey case currently before a lower court is expected to work its way up to that state's highest court.
    The Massachusetts case began in 2001, when seven same-sex couples went to their local city and town halls seeking marriage licenses. All were denied. That same year, the couples sued the state Department of Public Health, the agency that carries out marriage laws and administers required blood tests. Suffolk Superior Court Judge Thomas E. Connolly dismissed the lawsuit in May 2002, ruling that nothing in state law gives same-sex couples a constitutional right to marry. Bearing children has long been considered central to marriage, and same-sex couples alone cannot create children, he wrote in his decision.
    Legal observers always expected the legal battle over same-sex marriage to play out before the SJC, and the court agreed last year to hear the case. The justices' ruling will probably not come down for several months. The case will hinge on the court's interpretation of state law as well as the Massachusetts Constitution. The attorney general's office, which defends state agencies and state laws, argues that the marriage laws apply to the union of a man and a woman. Both the history of the law and past actions of the Legislature suggest that the statutes were intended to apply to heterosexual couples, Assistant Attorney General Judith S. Yogman argues in her office's brief.
    Such a far-reaching shift in public policy as allowing same-sex marriage should only come from the Legislature, the attorney general's office argues. In a statement, the attorney general's office said there is no constitutional right. ''What is not at issue is whether permitting same-sex couples to marry would be good public policy,'' the statement read. ''The Legislature, not the courts, should decide if, when and how to make such a far-reaching change in Massachusetts law.'' GLAD counters that prohibiting same-sex couples from marrying violates the equality provisions of the Massachusetts Constitution, the world's oldest functioning written constitution.
    ''From our perspective, the exclusion of same-sex couples should fail because it violates the basic promises of liberty and equality of all people under our constitution,'' Bonauto said. GLAD also argues that nothing in state law specifically prohibits women and men from marrying within their gender. Instead, state law lists several specific requirements for marriage: that the couple is not closely related, and that neither party is already married or underage. ''All of our clients meet those requirements, but they've all been turned away,'' Bonauto said.
    But a coalition of religious groups argues against tampering with the ''age-old'' concept of marriage. ''Marriage, like all things, must have a definition,'' said the brief filed by a group including the Masssachusetts Catholic Conference and the Greek Orthodox Diocese of Boston and New England. ''It cannot mean everything, or it will ultimately mean nothing. Throughout all history, marriage has been heterosexual.''
    Chester Darling, a lawyer who helped write the friend-of-the-court brief for two groups opposed to same-sex marriage, argues that supporters are turning to the courts because they cannot succeed in the Legislature. ''If the court goes the wrong way, I have a suspicion that there'd be a constitutional amendment,'' said Darling, who won a case in 1995 before the US Supreme Court barring a gay contingent from the St. Patrick's Day parade in South Boston. Last year, one of the groups represented in Darling's brief, Massachusetts Citizens for Marriage, failed to get a question banning gay marriage on the ballot.
    The seven couples say they wish to marry for the same reasons as heterosexual couples: to publicly dedicate themselves to each other and to legally protect their relationships. Four of the couples in the case have children together and they argue that their children deserve the same legal protections as children born to married parents. Hillary and Julie Goodridge of Boston will celebrate their 16th anniversary in April. But when Julie gave birth to a baby seven years ago, Hillary had difficulty getting hospital permission to see the child she considers her daughter. Another Boston couple, Michael Horgan and Edward Balmelli, have been partners for nine years and were joined in a civil union in Vermont in October 2000. Balmelli, a computer engineer at Lucent, would like to name Horgan as his pension plan beneficiary but cannot because they are not legally married. They carry with them health care proxies -- legal papers allowing the other to make medical decisions if one of them becomes sick or incapacitated -- in case emergency strikes. ''If one of us ends up in the hospital, we'd be strangers to each other,'' Horgan said. ''They'd have to contact one of our next-of-kin, because we're not each other's next-of-kin.'' Balmelli and Horgan are among the 4,400 out-of-state couples who have traveled to Vermont for civil unions.
    Dozens of organizations that oppose same-sex marriage have joined in 15 friend-of-the-court briefs. The attorneys general of Utah, Nebraska, and South Dakota argue that Massachusetts should not become ''the source of profound friction'' with other states and the federal government by radically rewriting marriage and exporting the controversy to other states. States routinely recognize marriages from other states. ''Massachusetts is a good and responsible participant in the national community of states,'' wrote Brent A. Burnett, Utah assistant attorney general. ''To legalize same-sex marriage would mar that record and wreak havoc.''
    A group of international human rights organizations -- including Human Rights Watch and the Coalition gaie et lesbienne du Quebec -- wrote a friend-of-the-court brief suggesting a broad trend around the world toward equal treatment for same-sex couples. They pointed toward Canada and South Africa as two countries considering same-sex marriage. But their brief was rebutted by a group of mostly international law professors, including some from Italy, Spain, and Australia. They argued that most countries recognize marriage as a union between a man and a woman.
    Supporters of gay marriage see hope in an SJC that has repeatedly expanded the legal notion of family in decisions over the past decade. The court has ruled that gay and lesbian couples can adopt children, and pioneered child visitation for the former partner of a lesbian. In 1999, however, the SJC struck down a policy that extended health benefits to unmarried partners of gay employees of the city of Boston, ruling it violated the state's legal definition of dependents. Even so, the court prodded the Legislature to change the law ''to reflect these new social and economic realities.''

Gay Couple Challenges Florida Ban on Homosexual Adoptions
Adam Liptak, New York Times- 3/2/2003

KEY WEST, Fla. -- Not long after school lets out, the cool and elegant home of Wayne LaRue Smith and Daniel Skahen, on a shady street near the historic district here, is transformed by the boisterous whoops of two boys. They exclaim at a bee on the porch, at the lime tree in the backyard, at the consequences of mixing dirt with water. They jump in the pool and welcome a visitor's applause at each twisting fall and cannonball. One is 5, the other 6; one white, the other of mixed race. They are bursting out of their skins with questions and energy.
    Mr. Smith, a 47-year-old lawyer, and Mr. Skahen, a 36-year-old real estate broker, would like to adopt the boys, who have lived with them as foster children for about two years each. But they are a gay couple and Florida is the only state that forbids any adoption by a homosexual. On Tuesday, a federal appeals court in Atlanta will hear their challenge to the law.
    Gay people are the only group categorically restricted from adopting children in Florida. Even people who have abused drugs and alcohol or people who have a history of domestic violence may adopt under some circumstances. State courts have upheld the law, with a state appeals court ruling in 1993 that the ban could be justified because homosexual parents are unlikely to be able to give heterosexual children sound dating advice. But this is the first time a federal court has considered the ban. The Supreme Court has said that states are required only to offer plausible rationales for laws that single out homosexuals. Florida officials have offered two.
    Judge James Lawrence King of Federal District Court in Miami rejected the first, that the law was a "legitimate expression of public morality as it bears on the questions of what environments are best for children, and what groups of people are entitled to recognition as families." "The court," he wrote, "cannot accept that moral disapproval of homosexuals or homosexuality serves a legitimate state interest." But he accepted the second reason, that children are better off with married heterosexual couples.
    Children, the state's lawyers wrote, should be "raised in homes with married mothers and fathers due to the stability provided by marriage and the contribution of male and female influences to childhood growth and development, including heterosexual modeling." Judge King accepted that and upheld the law. He noted that the federal Constitution "is not a license for the courts to judge the wisdom, fairness or logic of legislative choices."
    Lynn Dennis Wardle, a law professor at Brigham Young University, said there was substantial justification for the law as a policy choice. "The gay couple involved in the Florida case is on face value very appealing," Mr. Wardle said. "I would still say that a mom and a dad would be better than those two men."
    Mr. Smith and Mr. Skahen, who agreed to discuss their case on the condition that the boys not be named, say this ignores reality, as there is a shortage of interested married couples in Florida, which has 3,500 children in foster care awaiting adoption. If history is a guide, a quarter of them will be placed with single heterosexuals. Matthew Coles, a lawyer with the American Civil Liberties Union Foundation, which represents the plaintiffs, said he would urge the appeals court to consider the plight of Florida's children.
    "Nobody was breaking down the doors to come in and take care of these kids," he said, referring to the two boys in Key West. "These people have given these kids a childhood they never would have had. If the State of Florida had an ounce of decency, they would be trying to find more parents like them."
    While the state has vigorously defended the adoption law, it also recently consented to a novel arrangement for the younger boy fashioned by a state judge here. In December, the judge, Sandra Taylor, made Mr. Smith and Mr. Skahen the younger boy's permanent legal guardians. She wrote that the men were "model parents," that the boy "is bonded and attached" to them "and is in a stable and nurturing environment." "He has progressed remarkably in school and is completely healthy," Judge Taylor wrote.
    The boy, who is big-hearted and talkative, learned something new at school not long ago, and he was eager to share it the other day. Standing with his right hand on his heart, he recited the Pledge of Allegiance, with grave seriousness. Then, for good measure, he sang the entirety of "God Bless America." Becoming his legal guardian, Mr. Smith said, is a mysterious half loaf. "We have all of the responsibilities but none of the rights," he said. He wondered, too, why the state would trust the couple with permanent legal custody of the boy but draw the line just short of adoption.
    Mr. Smith and Mr. Skahen, who have been together for 11 years, have not told the boys that they have become the younger one's guardians, in part because the boys are too young to understand and in part because a quirk to the law appears to forbid a similar solution in the older boy's case. And there is reason to think that he may be placed elsewhere any day now. Mr. Skahen said that when he booked a Disney cruise for their family for June, he paid for trip insurance, just in case. Mr. Smith said their best hope for keeping their family intact was that the older boy was, like many of the children in foster care in Florida, were not quite what prospective parents were looking for. "Nobody wants to adopt a 6-year-old with developmental problems who is biracial," he said , bitterness tinged with hope. He paused, because he had been too sweeping. "I do," he said.

Study Links Hyperactivity And Snoring
Reuters News Service- 3/3/2003

CHICAGO -- Some hyperactive children thought to be suffering from attention deficit disorder may just be overtired because they are bad sleepers or heavy snorers, researchers said. "To the parent, the message is if you have a kid who is hyperactive and snores, think about the possibility that the two may be connected," study author David Gozal of the University of Louisville said.
    In his study, published in the journal Pediatrics, Gozal found about one-quarter of 5- to 7-year-old children with mild symptoms of attention deficit/hyperactivity disorder (ADHD) also snored. In some cases, the breathing problems reached the level of sleep apnea, where breathing is blocked repeatedly through the night and sleep is disturbed. "Over the years, we have observed many of those cases who came off their ADHD medications once they were treated for their sleep apnea," Gozal said.
    As many as 5 percent of American children, a majority of them boys, are believed to be affected by ADHD, which is characterized by inattention, impulsiveness and overactive behavior. Gozal said some candidates for the disorder are prescribed drugs without a thorough evaluation.

Treatment Options for Drug, Alcohol Abuse Fading
Tracy Davis, Ann Arbor News- 3/3/2003

Lisa Short had been through treatment for alcoholism once before. But after she and her husband moved to Ypsilanti from Atlanta a year ago, she found herself without the support system she needed to stay sober. She relapsed. Soon she found herself at Dawn Farm, an addiction treatment and recovery center with an inpatient program. She stayed at the detoxification house for three days, then spent three months as an inpatient at the farm. After she left, she had a list of phone numbers for dozens of new friends. "As much as I hated going in there for three months, outpatient would have never worked for me," said Short, 29. "You go home at night and you're alone with all these thoughts, just getting into your head. ... I had to be somewhere where I couldn't have access to anything."
    Short was lucky to get in. Dawn Farm often has a waiting list for its inpatient addiction program. It's one of a dwindling number of inpatient substance abuse and chemical dependency treatment programs left in the state. Outpatient programs are being cut as well. Last month, Saint Joseph Mercy Health System announced the hospital would discontinue its chemical dependency day program and laid off 16 employees.
    Thirty years ago hundreds of beds were dedicated to inpatient substance abuse treatment in the Ann Arbor area, said Jim Balmer, president of Dawn Farm. At up to $600 a day for treatment, it was a cash cow for hospitals. But managed care came along and reined in what could be spent. The insurance industry saw some people repeatedly go to hospital-based treatment, and decided it didn't work, Balmer said.
    "There has been a substantial decline in access, particularly for intensive treatment, for drug and alcohol problems in the last 10 years," said David Rosenbloom, director of Join Together, an addiction research advocacy group and program at Boston University's School of Public Health. "This has happened in part because coverage has declined."
    Today, Michigan law requires minimum coverage from insurance providers of at least 20 outpatient visits, said Gene Farnum, executive director of the Michigan Association of Health Plans. But it is up to employers who buy health-care plans whether to purchase additional coverage. "It's easier to tell people we're going to pay only 50 percent of your behavioral health costs instead of 50 percent of your chemotherapy," Robbie Renkes, administrative director of Home for New Vision, an Ann Arbor nonprofit addiction treatment center that serves women.
    Perceptions of those with drug or alcohol addictions are often negative, advocates say, so when the belt needs tightening, behavioral health services get cut. "We still don't give enough to the idea that it's a disease," said Glynis Anderson, chief executive officer of Home of New Vision and a recovering addict. "The whole myth of the skid-row bum needs to go." Balmer agrees. "It's a chronic, progressive disease that's characterized as a weakness," he said. "I think we don't like the idea of something where people can lose control. Recovery has to do with admitting you can't control this. And I think we still come out of a moral culture where we see it as a sin or moral failing."
    While treating addictions can be expensive, treatment advocates say not treating them has its own costs. Many addicts wind up in jail. They hurt themselves or become ill, or hurt others. Seventeen percent of 712,000 prison inmates interviewed in a 1991 study said that they were trying to get money for drugs when they committed their crime, according to Join Together. And families with an addict accrue twice as much in health care costs as families without, Rosenbloom said, because of stress-related illness, injuries, abuse and physical illness.
    According to a report prepared for the National Institute on Drug Abuse and the National Institute on Alcohol and Alcoholism, substance abuse cost $246 billion in 1992 alone. Those expenses range from lost productivity and health care to crime. The institute concluded that the more treatment given to patients the better the results, and that patients who stay in treatment longer than three months usually have better outcomes than those who stay for shorter periods. Yet programs continue to close down as public sources of funding become harder to find and private employers and their insurers struggle to keep double-digit premium increases down.
    Rosenbloom said more than half of the inpatient treatment programs available a decade ago have closed down. Such cuts keep demand high for programs that are still operating. Home of New Vision treats about 400 women each year. Almost all of its programs, which include outpatient treatment, a service for the homeless, referrals and assessments, detox and transitional housing, are full. The story is similar at Dawn Farm, which usually has a waiting list for its inpatient programs. Dawn Farm, which offers detox, transitional housing, and long-term inpatient and outpatient programs, treated 1,600 people last year. Among them was Short, who graduated Sept. 19 and now works at a local veterinarian's office. "People don't realize how many different types of people this disease affects," she said.

Revising the Script on Mental Illness and Violence
Richard A. Friedman, New York Times- 3/4/2003

Some years back, I was the attending psychiatrist in the emergency room when A young woman ran in, pursued by her boyfriend. They had been arguing on the street when he became violent, and she desperately wanted protection. Once inside, he began punching her, and the security guards immediately restrained him. The boyfriend then demanded to see a psychiatrist, saying he was depressed. It did not take long to see that he was a con artist who was looking for a psychiatric label to excuse his violent behavior. The police were called, and he was arrested. As the man was led out in handcuffs, he was barely able to suppress a mocking smile, underscoring how he had cynically exploited a common stereotype about the tendency of the mentally ill to be violent.
    For decades, if not centuries, there has long been a lurid fascination with mental illness in popular culture, spurred in recent years by the unforgettable Norman Bates, the psychotic killer of Hitchcock's "Psycho" and Dr. Hannibal Lecter, the cannibalistic psychiatrist of "The Silence of the Lambs" and its sequel. Not just the psychiatric patients, but the therapists themselves have also been widely depicted as deranged, if not downright homicidal.
    Hollywood will be disappointed to hear it, but the real story about violence has just a minor role for the mentally ill. The fact is that the contribution of psychiatric illness to all violence is quite small. For example, a Justice Department study found that people with histories of mental illness were responsible for 4.3 percent of all homicides in the United States in a year.
    Even so, Americans remain anxious about the violent risk posed by the psychiatrically ill. So how large, really, is the danger? Until recently, most of the studies that supposedly showed links between mental illness and violence focused on the rates of mental disorders among the violent or the rates of violence among psychiatric patients in hospitals. Those studies were unpersuasive because of selection biases. Subjects who are arrested, incarcerated or hospitalized are by definition more likely to be violent or very ill and thus are not representative of the psychiatrically ill patients in the general population.
    Newer studies have examined community samples and can give more accurate estimates of the risk of violence among the mentally ill. Using the figures from the large Epidemiologic Catchment Area study sponsored by the National institutes of Health, Dr. Jeffrey Swanson at the Duke University Medical Center reported that the incidence of violence was five times as high among people with serious mental disorders as it was among those with no psychiatric illness. Among the serious disorders are schizophrenia, major depression and bipolar disorder. People who use alcohol or other drugs were found to be 12 to 16 times as likely to be violent as nonusers.
    Because psychiatric patients have much higher rates of alcohol and substance abuse than the population as a whole, a crucial question concerns the extent that alcohol and drugs contribute to violent acts committed by the patients. When alcohol was controlled for in the epidemiological study, the one-year prevalence of violence among subjects; with major mental disorders dropped, to 7 percent from 20 percent. That is still higher than the 2 percent prevalence of violence in subjects with no mental disorders or alcohol abuse.
    A study published in The Archives of General Psychiatry by Dr. Henry Steadman of the University of Pittsburgh School of Medicine also reported that substance abuse was a strong risk factor for violence. Psychiatric subjects who did not abuse drugs were no more violent than members of a control group who had no diagnosed mental disorders and did not abuse drugs. That study also followed the subjects for a year after they left their hospitals. It found that the highest rates of violence occurred before hospitalization.
    But in the year of treatment after being discharged, when psychiatric symptoms are likely to be lower, the risk for violence among patients was no different from that of people who did not have psychiatric disorders. This suggests that the violence is related to the level of psychiatric symptoms, not the psychiatric diagnosis itself. Though the study did not specifically monitor the treatments, it is reasonable to hypothesize that treating psychiatric illness may not just make patients feel better. It may also drastically lower the risk of violent behavior.
    One surprising finding in this study was that when psychiatric patients were violent, they tended to be violent with family members or friends. Only 14 percent of all reported violence was directed at strangers. It seems that a person is far more likely to be harmed by a psychiatrically ill family member or a friend than by a mentally ill stranger. This is not to say that certain psychiatric illnesses like schizophrenia and bipolar disorder are not associated with an increased risk of violence. They certainly are, but the risk is only modest.
    The fact is that an intoxicated alcoholic is far more dangerous than a schizophrenic person who is wandering the streets. Why then does the public fear of the mentally ill so far exceed empirical reality? One factor is the news media coverage of the acts of the criminally insane. The public was transfixed by the horrific crimes of Jeffrey Dahmer, which, despite their rarity, burned the image of a deranged killer in the public mind.
    A deeper clue to the stereotyped the violent psychiatric patient comes from Alfred Hitchcock. What made his vision so terrifying was its accuracy. Ordinary people in the grip of ordinary passions are capable of extraordinary acts of horror and cruelty. He was rumored to have said once, when traveling in the countryside, that it all seems so peaceful, but that the perfect crime happens there every day. Nothing, in other words, is more frightening than discovering the darkness beneath the apparently normal and mundane. So it seems that the stereotype of the violent mental patient makes people feel safer by displacing and limiting the threat of violence to a small, defined group. After all, who could live with the reality that the nice guy next door might be a rapist or serial killer?

New Michigan Forensic Psychiatry Center to Open
Chong Pyen, Ann Arbor News- 3/4/2003

You might think the sprawling complex taking shape off US-23 south of Ann Arbor is a college dormitory campus or a retirement village until you notice the 200 surveillance cameras, numerous checkpoints and perimeter fences with motion detectors. The complex, consisting of residential wings connected by concourses to a town square, complete with a barber shop, stores and gazebos, is the $95 million Center for Forensic Psychiatry. It will house some of Michigan's most disturbed -- and potentially dangerous -- people under tight security. The 335,000-square-foot facility in York Township is scheduled to be completed in July, replacing aging buildings to the south that opened in 1966.
    Resembling a series of airport terminal concourses, the complex houses two two-story patient-care buildings, each containing four inpatient units. With each unit designed for 30 beds, the center's capacity will be 240, including 30-34 beds for women. The building design allows expansion to 272 beds, said Ina Whitney, administrative officer for the Michigan Department of Community Health assigned to the forensic center.
    In addition to the inpatient population, the center will evaluate 4,000 people a year to determine whether they are competent to stand trial and whether they need treatment. "All the folks here have serious mental disorders and have been ordered to stay here," said William H. Meyer, director of the center for nearly three decades. But he cautioned: "It's not a prison. It's a psychiatric hospital." Patients will have maximum freedom within the secured sections of the complex, which is designed to "simulate an old-fashioned small town," he said.
    They will be allowed to stroll down the wide concourses called Main Street, which converge on the Town Square, or courtyard, he said. Other amenities include a beauty salon, stores, a library, a gym, a dental clinic and an auditorium equipped with multimedia equipment. "Security is quite tight," Meyer said. "The fences surrounding the facility are staffed 24/7. The motion detection system picks up unwarranted movement. We don't want people to leave. They are a clear danger to themselves and others. They need treatment in a very secure setting." In addition to 200 cameras for visual monitoring, security measures include employee-carried personal security devices to summon help in case of danger. "We're very serious about escapes," Meyer said. The last time a patient escaped from the old facility was in 1986. William Scott Day, then 36, got away with the help of a security officer and fled South. He was later convicted of strangling a social worker in Tennessee.
    Among the center's former and current residents are those who have made headlines in high-profile criminal cases. Chester L. Posby was one of them. He was convicted in the 1992 shooting death of a U-M physician John Kemink. Posby, then 74, shot Kemink three times with a .380 semi-automatic gun at the Ann Arbor hospital. He was found guilty but mentally ill, and instead of spending the rest of his life in prison he was confined to the forensic center.
    The center was first located on the grounds of the Ypsilanti Regional Psychiatric Hospital, formerly Ypsilanti State Hospital, on a "temporary basis" in 1966 but has stayed there since. The hospital closed in 1991. The 210-bed facility provides diagnostic services in criminal cases and psychiatric treatment for defendants declared incompetent to stand trial or those acquitted by reason of insanity. The longest-staying patient arrived there in 1974.
    The patients' daily routine begins with breakfast at 7:30 a.m., followed by customized or voluntary activities and classes totaling 30 hours a week. Programs include anger management and substance abuse classes and Alcoholics Anonymous and Narcotics Anonymous meetings. "Each patient has his own thing," Meyer said. "Some patients respond to music very well and undergo music therapy. It all depends on individual needs."
    Once the new facility is up and running, the current forensic center building will be torn down, as have been the buildings that previously housed the Ypsilanti Regional Psychiatric Hospital. State officials will then have to decide what to do with the remaining 700 acres of vacant land. Last year, the land had been considered for NextEnergy, an alternative power research program, but the project moved to Detroit. With no plans to develop the site, state officials may put it on the market.

Forcing Mentally Ill on Trial To Take Drugs Is Pondered
Linda Greenhouse, New York Times- 3/4/2003

WASHINGTON -- An inconclusive Supreme Court argument today on whether mentally ill criminal defendants may be medicated against their will to make them competent for trial reflected the essential difficulty and delicacy of the mix of law and psychiatry that the case presented. "It doesn't fit comfortably in any setting with which we're familiar," Justice Sandra Day O'Connor observed as she asked a government lawyer how to balance the competing interests in such a case.
    The defendant, Dr. Charles T. Sell, is a St. Louis dentist who was indicted in 1997 by a federal grand jury on Medicaid and insurance fraud charges. His case has a number of complexities, including a subsequent indictment for conspiring to murder a federal witness and an F.B.I. agent, but the Supreme Court framed the question more narrowly when it accepted his appeal four months ago: whether it violates the Constitution to forcibly administer antipsychotic medication in order for the government to bring someone to trial for nonviolent offenses.  Dr. Self's diagnosis is "delusional disorder, persecutory type." Essentially, he believes that the F.B.I. is conspiring against him. He is being held in the federal prison system's medical center in Springfield, Mo.
    Both Dr. Sell and the government shared a common starting point, that as an aspect of the individual liberty protected by the Constitution's due process guarantee, people do have a substantial interest in avoiding unwanted mind-altering medication. Michael R. Dreeben, a deputy solicitor general arguing for the government, described the individual liberty interest as substantial enough to justify placing an extra burden on the government to justify the need for medication.
    But from there, the two arguments diverged. Mr. Dreeben said the government had met that heightened burden, despite the nonviolent nature of the felony charges the court was considering. The government has a "compelling interest" in bringing criminal defendants to trial and in "maintaining social order and peace" through resolving serious criminal charges, he said.  Mr. Dreeben said that medication had the proven ability to restore mentally ill defendants "to a point of rationality where they can decide what they want to do with their life." A defendant might rationally choose to go to trial rather than face being "warehoused" in a mental health institution, he said.
    Dr. Sell's court-appointed lawyer, Barry A. Short, argued that the balance tilted clearly in favor of his client, whom he described as dangerous neither to himself nor others and whose nearly five years of pretrial confinement was already longer than the sentence the federal guidelines would impose had he been tried and convicted. Dr. Sell has a fundamental right to refuse medication, he said, adding that "under these circumstances, I do not see any compelling interest whatsoever in prosecuting this defendant." He said that although Dr. Sell was incompetent as a legal matter, he was "medically competent" to understand his situation and make his own decisions.
    The United States Court of Appeals for the Eighth Circuit in St. Louis upheld a federal district court's decision that the government's request for medication was justified. But although the Supreme Court had accepted Dr. Sell's appeal, Sell v. United States, No. 02-5664, a number of justices today expressed doubt about whether the court should actually decide the case. Since the lower courts addressed the question of whether someone may be medicated in order to stand trial, their decisions were, by definition, pretrial orders. Under the ordinary rules of appellate procedure, pretrial orders lack finality and are not appealable unless they come within a few recognized exceptions.
    So shouldn't Dr. Sell be required to proceed to trial and to challenge any unwanted medication after the fact or in a civil lawsuit, Justice Antonin Scalia wanted to know. "I'm concerned that a new exception could disrupt criminal trials substantially," Justice Scalia said, asking what would happen if a medicated defendant decided in the middle of a trial that he wanted the medication to stop. "I see all kinds of problems with immediate appeals," he said. Chief Justice William H. Rehnquist and Justice O'Connor also appeared doubtful of the court's jurisdiction to proceed with the case.
    The last-minute emergence of the jurisdictional issue was surprising, given that neither side had identified it as a problem. The justices had issued an order last Friday afternoon instructing both lawyers to be prepared to discuss whether the court has jurisdiction, and directing them to file briefs on the issue this Friday.
    If the court finds itself unable to decide this case, it may soon have an even more highly charged case to consider. The Eighth Circuit decided another involuntary medication case last month, ruling 6 to 5 that a mentally ill death row inmate can be forcibly medicated in order to made competent to be executed.
    The issue of forcible medication is highly controversial and has split the mental health professions. In the case today, the American Psychological Association filed a brief on behalf of Dr. Sell. It warned that the same drugs that restore a defendant to competency "can prejudice the defendant in the eyes of the jury" by creating the appearance of boredom or restlessness. The American Psychiatric Association filed a brief for the government, arguing that medications that restore a defendant to competency are often the most medically appropriate way of treating the mental illness. "The court should not ignore the real costs of leaving a defendant untreated," the psychiatrists said.
    In addition to due process and fair trial rights, Dr. Sell's supporters also raise objections under the First Amendment to involuntary mind-altering medication. A brief submitted by the National Association of Criminal Defense lawyers tells the court that if Dr. Sell testified under the influence of medication, "his words would not be his own" but would be the government's.
    The justice most sympathetic to his position today was Anthony M. Kennedy. "I don't understand the government's basic authority to do this at all," Justice Kennedy said to Mr. Dreeben, the government's lawyer. Justice Stephen G. Breyer, on the other hand, appeared skeptical of Dr. Sell's argument. "There are a lot of seriously ill people whom these drugs help a lot," he told Mr. Short, Dr. Sell's lawyer.
    The court seemed to find the case almost exasperatingly difficult. "What is your solution to this dilemma?" Justice Scalia asked Mr. Short. "We can't try him because his mind is not working properly but you say he's entitled to refuse the drugs that would make his mind work properly. It's just a crazy situation. What can we do about it?"

Massachusetts Court Peppers Lawyers on Same-Sex Marriage
Kathleen Burge, Boston Globe- 3/5/2003

The justices of the state's highest court yesterday plunged into the debate about whether women can legally marry women and men can marry men, vigorously questioning lawyers on both sides of a lawsuit seeking the right to same-sex marriage. The lawyer for seven gay and lesbian couples who hope to make Massachusetts the first state to sanction same-sex marriage was just a minute into her argument when she was interrupted with questions from the justices. ''Why should we do something that virtually no other state has done?'' Justice Judith Cowin asked. ''This court should do so because it is the right thing to do,'' said the lawyer, Mary Bonauto. ''The exclusion of the plaintiffs from marriage . . . violates the fundamental right that these plaintiffs enjoy with all others in this commonwealth.''
    During the half-hour hearing, the justices pummeled the lawyers with questions about the purpose of the state's marriage laws, the role of the court, and an earlier court decision allowing gay couples to adopt children. One justice questioned whether legalizing gay marriage would also allow polygamy. Justice Roderick Ireland questioned Bonauto about arguments from state lawyers who say the question of sanctioning same-sex marriage belongs with legislators. ''Why do you think that this is an issue that we should decide?'' Ireland asked. ''I think it's an issue this court should decide because it's the institutional obligation of this court to decide constitutional issues,'' Bonauto answered.
    Justice Martha Sosman questioned whether allowing same-sex marriage would also allow polygamy. ''What would the difference be?'' she asked. Bonauto said that neither the Legislature nor the state's highest court has ever suggested that marriage should be made up of more than two people.
    The couples' lawyer and other same-sex marriage supporters argue that the state constitution's protections of equality and liberty allow citizens to choose whom they want to marry. The state attorney general's office, which is defending the state's right to deny marriage licenses to same-sex couples, argues that the state constitution doesn't provide such rights.
    Justice John Greaney asked Assistant Attorney General Judith Yogman whether she saw the same paradox he did in allowing same-sex couples to adopt children, but not to marry each other. ''Are those ideas somewhat at odds?'' he asked. ''Not at all, your honor,'' Yogman said. ''Adoption is one thing. Marriage has many other responsibilities and benefits associated with it other than child-rearing.'' Did she agree, he asked, that the modern definition of family has ''gone far beyond the notion of two heterosexual people married and having children?'' Yes, Yogman said, but that still didn't establish a constitutional right to same-sex marriage.
    The justices' ruling will probably not come down for at least several months. More than 200 people turned out to hear the arguments, packing the courtroom and spilling over into the hallway. The morning unfolded calmly, without protests or pickets. The case has attracted national attention, with dozens of groups on both sides of the issue weighing in with friend-of-the-court briefs. Some religious groups argued that same-sex marriage is immoral; local and state bar associations supported the seven couples; and law professors turned in legal briefs on both sides of the debate.
    The state that has come closest to same-sex marriage is Vermont. After a similar legal case there, the Vermont Supreme Court ruled in 1999 that the state constitution guarantees gay and lesbian couples the same benefits and protections given to heterosexual couples. The state's Legislature, faced with a choice of allowing gay marriage or a similar domestic partnership, created civil unions that bring many of the same benefits of marriage but aren't recognized beyond that state.
    The Massachusetts case began two years ago, when the seven couples sought marriage licenses and were rejected. They lost their first court battle, when Suffolk Superior Court Judge Thomas E. Connolly dismissed their case, saying the Legislature should decide the question. Bearing children has long been considered central to marriage, and same-sex couples alone cannot create children, he wrote in his decision. The seven couples appealed, and the SJC agreed to hear the case. The case will determine only whether the state sanctions civil same-sex marriage; if the seven couples prevail, churches would still decide whether to marry same-sex couples.
    For supporters of same-sex marriage, yesterday was a day of hope. After the arguments, some supporters hugged each other and Bonauto's voice trembled when she spoke to reporters. ''This is a historic day in Massachusetts,'' she said, as supporters cheered and clapped. ''The seven plaintiff couples had their day in court. Their families are equal families in this Commonwealth. They should have the same rights as all other families enjoy.''
    The 2000 Census found more than 17,000 families in Massachusetts living in same-sex households, she said. As Bonauto spoke, the seven same-sex couples stood behind her. ''For 32 years, I've loved Gloria and wanted to marry her,'' said Linda Davies of Orleans, about her partner, Gloria Bailey. ''And I think after today, I'll finally get to do that.'' Gina Smith and Heidi Norton of Northampton, two other plaintiffs in the lawsuit, say they always try to keep with them copies of their health care proxies, legal papers that give each the right to make decisions for the other if one of them should become ill or incapacitated. Otherwise, hospitals could refuse them access to each other since the two women, the parents of two young boys, are not legally related. ''But even that big stack of documents,'' Norton said, ''does not feel like it has the weight of a single word: marriage.''

Church Hires Psychologist Who Doubts Repressed Memories
Wendy Davis, Boston Globe- 3/5/2003

A controversial psychologist who has authored studies challenging repressed memories of sexual abuse is expected to present testimony for the Archdiocese of Boston when the first civil lawsuits against church officials go to trial. In papers to be filed today in Suffolk County Superior Court, church lawyers will notify Judge Constance M. Sweeney that they intend to elicit testimony from Elizabeth Loftus, a professor at the University of California, Irvine, to defend the church against charges that the Rev. Paul R. Shanley molested plaintiffs Gregory Ford and Paul Busa. Both Ford and Busa have said they were sexually abused by Shanley as children, but did not remember the events until 2002. Their lawsuits against church officials are the first civil cases expected to go to trial in Massachusetts stemming from the recent scandal.
    Loftus confirmed she has been hired, but said she did not yet know enough about the facts of the cases to assess the reliability of the plaintiffs' memories. ''I have been retained, but I have not fully studied these materials,'' she said. Co-author of ''The Myth of Repressed Memory,'' Loftus frequently testifies for the defense in trials where plaintiffs contend they remembered a traumatic event years after it happened. Cases in which she has been a witness or consultant include the McMartin Preschool molestation case, the Rodney King trial, and the Hillside Strangler case. Much of her research focuses on the weakness of memory. She contends that people can confuse memories of real events with events that they either imagined or that were suggested to them. Other specialists, however, including researchers the plaintiffs intend to call as witnesses, say highly stressful events such as sexual assaults can induce amnesia and victims can later ''recover'' valid memories.
    The reliability of repressed memories will probably be a significant issue in the upcoming lawsuits because many of the alleged victims, including Ford and Busa, will contend they did not come forward sooner because the trauma of being molested caused amnesia. Ford, now 25, alleged in court papers that Shanley began molesting him when he was 6. Ford alleged the abuse occurred between 1983 and 1989. He only remembered it, he said, after his parents showed him a profile of Shanley that appeared in The Boston Globe on Jan. 31, 2002. ''This clearly now is shaping up as a situation where the memory of Gregory Ford is going to be attacked,'' said Ford's lawyer, Roderick MacLeish Jr., who represents approximately half of the 500 victims suing the church and its leaders. MacLeish estimated that at least 25 to 40 other clients suffered some form of amnesia after having suffered the alleged abuse.
    J. Owen Todd, Cardinal Bernard Law's lawyer, said the church intends to call Loftus to rebut plaintiffs' memory specialists. MacLeish has included a number of memory specialists on his list of potential witnesses, including Dr. Bessel A. van der Kolk, a leading researcher on how trauma influences memory, and Dr. Stuart Grassian, a psychiatrist who has treated victims of former priest James R. Porter. Grassian, while declining to discuss the specifics of Ford and Busa, said that recovered-memories cases are not especially different from other trials where the facts are in dispute. ''In any case, there are often conflicting views about what really happened,'' says Grassian. ''There's fallibility in all memory and all eyewitness testimony.''
    Whether Loftus or the other memory experts will be allowed to testify will be up to Sweeney, according to legal specialists. Suffolk University Law School professor Michael Avery said he thought Sweeney would probably hold a pretrial hearing to determine the scope of Loftus's testimony. ''General experts on the topic of repressed memory could be helpful to a jury,'' said Avery.

Oregon Cuts Off Prescriptions to Mentally Ill
Timothy Egan, New York Times- 3/5/2003

PORTLAND -- In a state that says it is already so short of public money it does not have enough to keep all the schools open and prosecute many criminals, Oregon took a drastic step this week to cover budget shortfalls: It cut off medications to thousands of schizophrenics, manic-depressives, drug addicts and other mentally ill people. A decade ago, Oregon was widely hailed as a pioneer in providing health insurance, including prescription drug coverage, not only to the poor, but also to people who make just enough money that they do not qualify for federal Medicaid. Now, in a reversal that has stripped a once-ambitious program to its core, Oregon has pared back the insurance, and removed prescription drug coverage for things such as mental illness and drug addiction. About 100,000 poor people are suddenly scrambling for the basic medications that allow them to function.
    Officials are looking for some way to restore some of the health program, but admit they will not be able to offer anything like the expansive benefits of the past. Most of the cuts went into effect Saturday, but others started Feb. 1, just days after Oregonians voted in a referendum against a tax increase to balance their budget. Lawmakers in Washington are facing a $2.4 billion overall budget deficit. Gov. Gary Locke is determined not to raise taxes to make up the gap and has proposed controversial cuts to programs for the poor, disabled and mentally ill.
    For Dave Cesario, 45, of Portland, who is HIV positive, diabetic and taking methadone to stave off addiction to heroin, it meant going cold turkey on Saturday. "I'm just numb -- I don't know what to do," said Cesario, who lives with his disabled wife and 12-year-old son. "My only hope is that the drug companies will have mercy and I'll be able to get some free samples." For Karen Hansen, 50, who has prescriptions for everything from anxiety disorder to high blood pressure, the cutoff means taking only the few drugs that will keep her alive. She lives on $689 a month in Social Security disability payments, and her monthly prescription bill -- without assistance -- is $615. "I don't buy the newspaper, I eat hot dogs that they give out free, and get other meals from the food bank," said Hansen. "But that only saves about $200."
    The step is just the latest response to a budget crisis that forced state officials to make nearly $600 million in cuts in the past two years, and will require another $2 billion in reductions, according to projections, in the budget cycle that begins this June. Hit by a harsh recession after a series of tax-cutting measures pared the budget to the bone, Oregon, which has no statewide sales tax, now lacks money for health care, schools, prisons and prosecution.
    Dr. Patricia Kullberg, medical director of the health department of Multnomah County, which covers Portland, said she just did something she had never done in 21 years as a family physician: She advised a patient which medications he could stop taking and suffer the least. The patient lost his prescription drug benefit for arthritis, depression, high cholesterol and hypertension. "I feel like I'm living in some foreign country where suffering is routine," she said. "It's scary. What we're doing is condemning people to the long-term consequences of their diseases."
    The hardest hit, say state officials, are the mentally ill. Jim Underwood, a mental health specialist with Cascadia Behavioral Healthcare in Portland, said his patient Robert Seaman, 47, a paranoid schizophrenic, is likely to become delusional again without his medications. Seaman had trouble responding to questions of an interview. "Without his meds, he has trouble with getting food, shopping, all the basic survival things," Underwood said.
    The Legislature is working this week on a temporary patch. The proposal would take video poker and cigarette tax money that had been promised to cities, and drain a reserve fund set aside for schools to make up an immediate shortfall of $250 million. Mary Ellen Glynn, a spokeswoman for Gov. Ted Kulongoski, a Democrat, said the next two-year budget could be even worse, because voters refuse to raise taxes. "We're in a real double-bind," she said.
    Advocates for the mentally ill put the issue more starkly. David Eisen, clinical director for Central City Concern, a private non-profit agency that provides care for drug addicts and the mentally ill, said people whose basic medical needs were met by prescription drugs costing the state about $90 a month, per person, are now going to start showing up in hospital emergency rooms, or jail, where they will cost the state far more. "The people who made this decision thought they could save a few million dollars," Eisen said. "But the crime rate will rise, emergency rooms will be flooded with people and in the end, the state is going to pay five to eight times more than they would have saved."
    In most states, the federal Medicaid program covers the basic medical needs of the poor. But Oregon was given a federal waiver to shape its own program because it promised to provide near universal coverage of the poor -- something only a handful of states have tried to do. In good times, the Oregon plan worked, and was widely praised as a resourceful use of limited public funds for health care. One measure of the success was that Oregon has one of the lowest percentages of mentally ill people in institutions. Prescriptions and mental health clinics have allowed people to work, or live in community settings, without presenting a danger to themselves or others, state health officials say.
    Critics of the plan, however, said it was allowed to grow too fast, and even though Oregon rationed out services -- drawing up a list of what would be covered and what would not -- it still proved too generous. State Rep. Jackie Winters, a Republican, said that over the past 20 years, social services in the state have quadrupled, far in excess of population growth. "We expanded beyond the basics, and now we realize you can't cover everything you want," she said. Now a number of legislative committees are studying ways to redo the Oregon Health Plan. Even if state revenues become less anemic, the plan is unlikely to be as ambitious or far-reaching as it was, both supporters and opponents say.

Seattle Drug Court Offers a Way Out
M.L. Lyke, Seattle Post-Intelligencer- 3/5/2003

The woman called Mom picked at her face, spaced out in the middle of a sentence, spent hours Dumpster-diving and disappeared for days at a time, leaving her adolescent daughter to care for three little kids in a house piled 4 feet high with junk. "She acted retarded. She thought she was all skinny and beautiful, but she was anorexic and gross," says 17-year-old Tara Campbell, whose mother, Michele, was busted for possession of methamphetamine in Marysville in 1999, adding her name to the long file of female users bogging down America's criminal justice system.
    In the months leading up to the bust, Tara remembers a houseful of freaky strangers who stole her socks and underwear and flopped wherever they crashed. They zoned out for days on end, chemicals oozing from their pores. "When they slept, that smell came off of them. It stunk so bad," Tara says. On Sept. 21, 1999, Tara was called into the office at Marysville-Pilchuck High School and told about the drug raid. Maybe she should have been bummed that her mother was going to jail. But she didn't really have a mother. "I was glad when she was busted," Tara says. "I thought, 'Thank God, it's over.' "
    For Michele Campbell, another kind of "it" was just beginning. After a quick stint in jail, she spent the next couple of months in a chemical daze. Child Protective Services wouldn't let her see the kids, who'd been farmed out to relatives. She would try drug treatment and fail big-time. Again and again, she would return to the crank, snorting it or putting it in capsules to swallow. "When I didn't do it, I couldn't even get out of bed," she says. But Michele the tweaker was about to get lucky -- and smart. Picked up again in '99, she was recommended for Snohomish County's Drug Treatment Court, presided over by Judge Richard Thorpe. Michele wanted the kids back. She wanted her life back. She began weaning herself off the meth, a bit at a time.

The mules
Drug users like Michele are the largest factor driving the boom in female inmate populations nationwide. Drugs account for about half the rise in female crime. For males, the figure is one-third. Women offenders are more likely than men to be using at the time of their crime, and, according to a new study, more likely to be addicted to drugs at an earlier age. "Substance use can sink into abuse and addiction more quickly for girls and young women than for boys and young men, even when using the same amount or less of a particular substance," reads the report from the National Center on Addiction and Substance Abuse at Columbia University.
    Female addicts typically come into courts charged with theft, prostitution, forgery, embezzlement -- means to feed a habit. Or they are popped for dealing and delivering, often for a bad-news boyfriend. "The men call them 'the mules.' They carry the drugs," says Mary Whitaker, a national specialist on women and crime. She says women are particularly hard-hit by what she calls the country's "draconian" drug laws. That and a peculiar kind of loyalty. "If you get busted, you can, one, narc on somebody above you or, two, do the time. Because females are relationship-based, they take the fall," Whitaker says.
    Criminal justice experts say treatment programs tailored to women aren't keeping pace. And throwing female offenders in the can doesn't work, either. As soon as they get out, the old circle of friends is waiting. "We bring them in for a year, and they're healthy, clean and sober when they leave," says Lourie Happy, a corrections officer at the Snohomish County Jail. "But they come right back in, and they're so strung out. It's hard to watch it."
    The drug court is one program that seems to work. Drug courts offer addicts an option: They can take the charge and do the time -- typically 20 days on a first-time possession -- or sign up for the court's rugged yearlong regime of counseling, therapy sessions, weekly court sessions and self-support meetings, and random U.A. checks -- urine analyses.
    Success stories abound in Judge Thorpe's court, where meth is a growing influence, and women are a growing presence. "I've been on the bench for 14 years. I'm seeing far more women than I used to," Thorpe says. "Before, it was about 10-12 percent women. Now it's closer to 35-40 percent." The women, he says, can be heartbreakers. "There is nothing more pitiful than a woman with no place to go, who is so addicted that she just can't or doesn't stay in treatment long enough to get clean."
    During Thursday afternoon drug court sessions, his courtroom is packed to overflowing, with attendees sitting in aisles and leaning against walls. Some bounce smiling babies on their knees, some sway on their bench, nodding off. Supporters bring long-stemmed roses and Mylar balloons with the word "Congratulations" to hand to addicts successfully kicking their habits. One by one, Thorpe calls his charges before him. When he announces "good news" -- a certificate for completion of a treatment phase -- the room breaks out in applause. "Bad news" -- missed appointments and dirty urine analyses -- receive only silence. Everyone in the room knows how thin the line is between stoned and sober.
    "The U.A. you dropped, is it going to be clean?" he asks a young man standing before the bench. "It should be," the man answers. The judge stares, hard. "I know it should be, but will it be or not?"
    To graduate the court, offenders must have completed the yearlong program with a minimum of six continuous months of clean urine checks. They must also pay $627, show proof of employment and high-school diploma or G.E.D., and have a sponsor and a home group.
    Thorpe, a father figure to his recovering users, proudly shows off the "before" and "after" picture albums he keeps in his chambers of graduates. The "before" booking photos show wasted, sunken-eyed men and women after a hard day's night. "After" photos are snapshots of neatly dressed graduates, reunited families, moms with new babies. One of those "after" moms is drug court graduate Michele Campbell.

Snipers on rooftops
Michele became pregnant with her fifth child, a happy, big-eyed girl named Cierra, after she signed up for drug court. Cierra was born "clean and sober," her proud mother says. Michele has all the kids back, a new home and a future. She says she has been off crank for three years. She credits drug court. "Locking me up. What would that have done?" she asks. "I'd get out, find more dope, get high, get busted and go back to jail."
    Still, the past breathes close behind her. She can't ditch the awful memories of the '99 bust. The snipers on rooftops. The SWAT team with bullhorns. The officer taking her 2-year-old son, Cody, out of her arms. She describes hearing Cody bawling for her from the other side of the plate-glass window in the squad car. "This little boy, his nose running, screaming his head off, he can't reach his mom," she says.
    Yeah, she still thinks about meth a lot, she says. All addicts do. "The kids, they think Mom's fine now. They don't know how easy it would be to go back on," she says. "But when I think of all the damage I caused, I know I would never want to use again. . . . The reality of what I did hurts so bad," she says, her sea-green eyes tearing up. She picks up a picture of herself from her tweaker days. It shows a skinny, haggard woman with dark circles under her eyes. "I thought I was so pretty," she says, shaking her head. "I don't even recognize myself."

Supreme Court OKs Online Sex Offender Postings
Associated Press, 3/6/2003

WASHINGTON—The Supreme Court ruled Wednesday that states may put pictures of convicted sex offenders on the Internet, a victory for states that use the Web to warn of potential predators in neighborhoods. In a separate narrow ruling, the court turned back a challenge from offenders who argued they deserved a chance to prove they aren't dangerous to avoid having their pictures and addresses put on the Internet.
    The decisions came in the Supreme Court's first review of what are known as Megan's laws and have far-reaching implications because every state and the federal government have sex-offender registry laws. The laws are named for 7-year-old Megan Kanka, a New Jersey girl kidnapped, raped and killed in 1994 by a convicted sex criminal who lived in her neighborhood. The cases, from Alaska and Connecticut, required justices to balance the rights of offenders with the public safety interest in keeping tabs on people who may commit more sex crimes. The court came down on the side of public safety in the Alaska case, but left the door open for future constitutional challenges of Megan's laws in the second case.
    Justices, by a 6-3 vote, rejected arguments of two Alaska sex offenders who contended that they already served time for sex crimes before the Alaska registration law was passed and were punished a second time with the registry. The law requires convicts to give police personal information four times a year or risk more prison time. Justice Anthony Kennedy said that the law is not punitive, and therefore it does not punish the inmates after the fact. "Our system does not treat dissemination of truthful information in furtherance of a legitimate governmental objection as punishment," he wrote. "The purpose and the principal effect of notification are to inform the public for its own safety, not to humiliate the offender." In a dissent, Justice Ruth Bader Ginsburg said that "however plain it may be that a former sex offender currently poses no threat of recidivism, he will remain subject to long-term monitoring and inescapable humiliation." Also opposing the court's ruling were Justices John Paul Stevens and Stephen Breyer.
    The court ruled 9-0 in favor of Connecticut, but did not address the constitutionality of requiring offenders to register without holding separate hearings to determine the risk posed by sex criminals who have completed their prison sentences before putting them in a registry. Chief Justice William H. Rehnquist, writing that decision, said that the case did not give the court the appropriate avenue to decide whether Connecticut's Megan's law violates substantive due process rights. Justice David Souter noted in a separate opinion that the court's decision does not affect future constitutional challenges to Megan's laws. The government had argued that it was not burdensome for offenders to report to police every 90 days to provide information, including their addresses, and to have their pictures taken, because all people have to fill out paperwork in government office to vote, register a car or get married.
    Justice John Paul Stevens said that in both rulings his colleagues "fail to decide whether the statutes deprive the registrants of a constitutionally protected interest in liberty." The cases are Connecticut Department of Public Safety v. John Doe, 01-1231, and Otte v. Doe, 01-729.

Texas H.S. Student Wins Battle to Start Gay-Straight Club
Kristen Hays, Associated Press- 3/6/2003

HOUSTON -- A school district settled a federal lawsuit Wednesday in a deal that will allow a 17-year-old student to establish a gay acceptance club at her suburban high school. ''We're going to be able to work toward spreading tolerance throughout the school,'' the student, Marla Dukler, said alongside her parents and attorney.
    The 1984 federal Equal Access Act ensures the right to form non-curriculum clubs in schools that receive federal funding. Such clubs at Klein High in Houston include Christian athletes, chess players and anglers. Dukler and 16 classmates applied to establish a ''gay-straight'' club last October. The district said the club application presented it as a support group to promote tolerance and nondiscrimination regardless of sexual orientation. After getting no answer from the district, Dukler sued the Klein Independent School District and school officials.
    The settlement allows for the club to be established and protects a district policy that requires written parental permission for students to participate. Dukler said all applicants have parental permission. She also said about 200 students signed petitions supporting the club, many of them heterosexual.
    Dukler said she has experienced harassment and taunting at school for being a lesbian, and she hopes the club will help alleviate such behavior. ''We'll see some opposition,'' she said. ''But by educating the students and faculty, it will be a lot easier for me to walk the hallways and for students coming after me to walk the hallways.'

Michigan Drug Court Program Encouraging for Teens
L.L. Brasier, Detroit Free Press- 3/7/2003

His parents were at the weary end of their frayed rope 15 months ago when it seemed that Ryan was headed for more trouble. Their son -- at 15 an alcoholic, petty criminal, chronic truant and runaway -- was facing a year behind bars after thwarting every attempt to control him at home. "I would hide his shoes to try to keep him home," his father Mitch said. "But he'd go right out the bedroom window, a second-story window, and disappear into the night."
    But instead of going tojail that day more than a year ago, Ryan's case was deferred and he was placed in a new juvenile drug court program. This week, he and his family were back in court for a celebration instead of a sentencing. Ryan, who doesn't want his last name used, and three other Oakland county teenagers were graduating from the drug court -- a 20-month-old program that is showing promising results. It was a moment of triumph for the youngsters and their families. As part of their graduation, the prosecutor asked the judge to dimiss the charge that had been pending for each of the youths . And the judge, with a bang of his gavel, sent the courtoom packed with family and friends into applause. For Ryan, now 17, it kept him out of juvenile detention and alcohol free for the past eight months.
    The program is based on a relatively new, nationwide approach to treating young addicts. Rather than jail them, drug courts keep them with their families while ordering intense substance abuse treatment and strict supervision by the court. Families also undergo counseling, and parents who are addicts -- as is often the case -- also are ordered into treatment. In their struggles, they are joined by a team of professionals. Along with the judge, there are probation officers, social workers, psychologists and lawyers.
    The rules are simple. The young offenders must live at home. They cannot use drugs or alcohol and must submit to two or three random drug tests a week. They are in daily contact with a probation officer and must attend school or work, and go to counseling sessions. Once a week they go to court, giving the judge a progress report. For the kids, there are immediate rewards for progress, such as field trips. And there are quick consequences for relapses, such as community service or a weekend in custody. So far, eight of 36 youths have successfully completed the program and an equal number have dropped out. The next graduation ceremony will be held in a month .
    Despite the heavy commitment of resources, the program is cheaper and, according to an independent review, more effective than locking them up. About 14 percent will commit new crimes during the program, the study found, compared with 70 percent of young addicts in the more conventional court system. Taxpayers spend $169 a day -- or $61,685 a year -- to house young drug addicts in county juvenile facilities, but only $36 a day ($13,000 a year) to treat a youth in the drug court.
    The key to success, say those who run the program, is constant, daily monitoring, particularly in the early months of rehab. "We know almost immediately when a kid is 10 minutes late to school," said Oakland County Circuit Judge Edward Sosnick, who heads the court. "We're teaching them to be accountable, sometimes for the first times in their lives," he said.
    The kids going into the program have already been in trouble with the law and are facing time behind bars -- the big stick officials use to convince them to give rehabilitation a try. The charges against them are pending while they are in the program. The charges are dropped for those who graduate. The participants, ages 14 through 17, are referred by probate court, other circuit court judges, police and schools. Those with serious mental illness or a history of violent crime are excluded.
    They aren't all success stories. About 27 percent of the kids are dropped in the first year, many because of repeated drug use. While the program is too new to track graduates' long-term progress, there are hopeful indications. "All I can say is stay clean," said Dan Bunner, 17, who was the first to graduate from the program in October. "Your life is better that way."

California Couple Charged With Abusing Mentally Ill
Andrew Blankstein and Jean Guccione, Los Angeles Times- 3/7/2003

A husband and wife were accused Thursday of taking 10 mentally ill adults out of licensed facilities and placing them unsupervised in dirty and unsafe conditions as part of a scheme to steal their government disability checks. Abraham and Alicia DeGuzman chose victims who were suffering from debilitating mental conditions and had no relatives, "zombified" some with drugs and warehoused them in slum-like squalor, according to affidavits in the case. One resident was forced to work for the DeGuzmans, two attempted suicide, others overdosed and one mutilated himself, according to warrants.
    Within an hour of the arrests, authorities shut down a facility owned by the DeGuzmans, the Parks Manor Guest Home for mentally disabled adults in the 1900 block of Oxford Avenue near downtown Los Angeles, and relocated 28 residents. The 10 victims cited in the criminal charges were previously removed from the substandard conditions. "They knew who didn't get calls and who didn't get visitors," said Glendale Police Officer Matt Irvine. "They drew from that group and they just spirited them away to squeeze the last pennies of profit from their government aid."
    The couple appeared dazed as they were taken into custody at 6:45 a.m. at their home in the 600 block of Corwin Avenue in Glendale. Abraham DeGuzman, 52, was jailed in lieu of $1.4 million bail. Alicia DeGuzman, 48, is being held in lieu of $750,000 bail. The Los Angeles district attorney's office charged each with 28 felonies, including abuse of dependent adults, grand theft, intimidating witnesses and conspiracy. The crimes allegedly took place at two Glendale homes owned by the DeGuzmans between Jan. 1, 2001, and May 2002.
    The 10 victims, ages 20 to 62, suffered from debilitating conditions including hallucinations, major depression, paranoia and violent outbursts, according to medical records obtained through the search warrants. They were moved more than a year ago when police shuttered one of the Glendale houses and the DeGuzmans closed the other. Six went to other care facilities. The remaining four returned to Parks Manor and were relocated by authorities Thursday. The victims are considered dependent adults deserving of special protections under state law. The DeGuzmans hid them in a nondescript home, authorities alleged.
    The DeGuzmans, allegedly with the help of a local credit union official, set up accounts for residents, taking most of their monthly $900 government disability checks. Residents lived on mattresses found stacked in a drafty garage and on a kitchen floor. The DeGuzmans instructed them to run from police and, if caught, to tell authorities that they rented the house from the DeGuzmans and pooled their money for rent, food and other living expenses, according to the affidavits. One longtime resident was allegedly forced to work for free in a now-defunct restaurant owned by the couple. Some tenants were so traumatized by the living conditions that they mutilated themselves and took overdoses of medication, according to the search warrants.
    At least three residents received injections of powerful and obsolete anti-psychotic medication designed to "zombify" patients rather than treat them, the warrants said. The drugs Prolixin and Haldol, once commonly prescribed to keep mentally ill adults docile, confused and submissive, were being used by the DeGuzmans as "a fiduciary equivalent of date-rape drugs," according to search warrants.
    The California Department of Social Services sought Thursday to revoke the couple's licenses to operate care facilities and bar them from ever again working in a licensed home. And the state Board of Registered Nursing will seek to suspend the license of Alicia DeGuzman, a registered nurse since 1975 with a clear disciplinary record, said Susan Brank, the board's assistant executive officer. Abraham DeGuzman's 73-year-old mother, Natalie Calantas Buendia, also known as Natalie DeGuzman, also was arrested Thursday and charged with dissuading a witness from reporting a crime. She is being held in lieu of $100,000 bail. Devere Warrington McGuffin II, the 59-year-old chief executive of California Adventist Federal Credit Union, was charged with grand theft and conspiracy for allegedly helping the couple set up improper accounts for the victims. He is being held at the Glendale jail in lieu of $110,000 bail.
    The arrests culminate a 14-month long investigation by the Glendale Police Department, the district attorney's office, the state Department of Justice and the U.S. Social Security Administration. It was launched after a resident overdosed on drugs at one of the DeGuzmans' homes. A Glendale police officer responding to an overdose call in 2001 in the 400 block of South Verdugo Road reported finding mentally ill adults in squalid conditions. The city later closed the home, which was owned by the DeGuzmans. Investigators said residents were forced to sign over their entire government disability checks, which were issued on the understanding that the victims were in a supervised care setting.
    Prosecutors alleged the DeGuzmans culled the most vulnerable and anonymous victims from Parks Manor, a licensed board and care facility, and moved them into the unsupervised living arrangements. Many received the highest level of disability pay because they required the highest level of care outside of hospitalization.
    One victim, who has been treated for schizophrenia since he was 5, was moved from Parks Manor to a garage in the 600 block of Corwin Street near the DeGuzmans' home, then to a particle board-and-rattan addition behind a house in the 400 block of South Verdugo Street, according to court documents. He admitted himself to a local hospital three times in 2001, claming he was suicidal, according to the search warrant affidavits. He told authorities that he wanted to kill himself "out of fear that he will cause his board and care to be shut down and its residents to be made homeless." He said Abraham DeGuzman dropped him off at a hospital emergency room each time he became ill but DeGuzman never entered the hospital.
Another victim, who was in a psychiatric hospital before he was placed in the DeGuzmans' care, stopped taking his medications, became depressed and slashed his arms, court records show. His doctor told authorities that he thought his client was receiving around-the-clock supervision at Parks Manor. His care was provided by another patient, a diagnosed schizophrenic, who is paranoid, suicidal and hears voices, according to court records. The caretaker has lived on the DeGuzmans' properties since 1989 and also was treated like an "indentured servant," being forced to work long hours in the kitchen of their restaurant without pay, according to authorities. Authorities allege that the DeGuzmans' stole at least $20,000 from the 10 victims in the last year, but said they believe there might have been many more victims during the last several years.