Dealing With the New 'Non-Traditional' American Family
Kate Rice, ABC News- 1/19/2004

Gina Smith and Heidi Norton of Northamption, Mass., have two sons. Norton is their biological mother, and Smith adopted them. They live in a community in which there are several gay- or lesbian-headed households, but when they travel, they meet families with no experience with gay families and sometimes encounter clumsy questions.
     While they may not fit the mold of what many Americans consider a typical family, they are a contemporary American family. There is no single typical American family anymore. "We're in the midst of a major change in the way families and marriage are organized," says Stephanie Coontz, a college professor and author of The Way We Never Were, American Families and the Nostalgia Trap and The Way We Really Are, Coming to Terms With America's Changing Families. "It's distressing, because all of the rules we grew up with no longer work and so we're having to learn new ways of thinking about families."
     Smith and Norton, both 39, head a family that helps others rethink their ideas of what a family is. When they're asked about themselves and their sons, Avery, 7, and Quinn, 3, they assume that questions are well-intended and that the clumsiness simply means that the questioner doesn't have the vocabulary to deal with the situation. "What's worked for us is stepping into the void and giving people some language to use," says Smith. "We would say things like, 'Avery is a very lucky boy who has two moms who love him,' so we just give them that language."

The 1950s Myth
Most children these days have buddies whose families are very different from their parents'. In fact, they quite possibly are growing up in such a family. Most people still believe in the two-biological-married-parents-with-kids model, says Alexis Walker, editor of the National Council on Family Relations' Journal of Marriage and the Family (www.ncfr.org). "Family is both a belief and a practice," she says.
     When she asks her students at Oregon State University, where she is a professor of human development and family sciences, if they think their family will be a mom, a dad, and children, most raise their hands. But practice is far different. When she asks if they come from a family like that, only a few put their hands up.
     Americans have to deal with the great myth of the 1950s, an era in which 60 percent of families consisted of a breadwinning father and a stay-at-home mother. But this model was actually a 15-year-aberration, fueled by post-World War II prosperity and a GI bill of unprecedented generosity that funded the education of returning war veterans, according to Coontz, a professor of family and history at Evergreen State College, Olympia, Wash., and co-chairman of the Council on Contemporary Families (www.contemporaryfamilies.org) The council's mission is to publicize the way the family is changing and to cover the consequences and implications of those changes.
Coontz says that for most of history, families have been co-provider families, with husband, wife and often children, all working to provide for the family.
     "The fact is that families have always been diverse, and they've always been in flux and we've always been worried about it. As far back as colonial days people were complaining that the new generation of families was not like the old one," she says.

No Single Model
The 21st century child-rearing family can take any number of forms. There's the 1950s model, one that is shrinking in number. An exact count is hard to come up with, but experts believe it's probably under 25 percent. Statistics show that today the majority of couples both earn income. Demographers estimate that only 50 percent of children will spend their entire childhood in a two-parent, married couple biological family, according to Coontz.
     Increasingly common are blended families, couples with children from previous marriages as well as the current marriage. Then there are single parents, families with adopted children, gay families with adopted children or biological children, foster families, grandparents raising grandchildren, and so on. Absent a single, cookie-cutter family model, the best definition of a healthy family is one that provides or performs certain core functions. These include basics such as food, shelter and economic support, according to Liz Gray, associate professor and family therapist in human development and family sciences at Oregon State University in Corvallis.
     But a family does much more, providing love and affection, a sense of identity and a feeling of belonging. Families also provide a worldview or a spiritual belief that can help make sense of the world, as well as rules and boundaries for appropriate behavior and skills for dealing with the world.
More than a decade ago, Gray co-authored Nontraditional Families: A Guide For Parents (http://www.cyfernet.org/parent/nontradfam.html), which remains a highly useful piece for parents today. Looking back, Grey says she would never use the term "nontraditional," because today, those "nontraditional" families have become the norm.
     Like any parents, Smith and Norton love to talk about how their family came to be, says Smith, and often handle curiosity by simply telling the story. Children had been part of each woman's life plan even before they met and fell in love 13 years ago, so it was only natural that they have children together. Smith says most people are accepting of their contemporary family. "If you present yourself as comfortable with who you are as family, they'll take their cues from you," she says. She finds that the fact that she and Norton have such respect for themselves that others approach them and their sons with that same respect.

Tips: How to Deal
     If you encounter a family that might once have been called nontraditional but aren't sure how to handle it, experts recommend first that you show respect no matter the others' family structure. Your children will closely follow your actions and their responses will mirror yours, as well.
     Some more of the experts' recommendations are below.
**Look at your own family, your brothers, sisters, aunts, uncles, cousins, friends, neighbors. Odds are, you'll see a variety of family structures. That will give you an idea of what your children are encountering in school, and give you a way to discuss the issues with them.
**Draw maps of families and extended families to help children understand family structure. Talk about it. Let children draw their own maps or pictures of families, then listen to what they have to say about it.
**Your child has a friend whose family structure is one you're uncomfortable with. What do you do? Deal with it as though you were moving to a new neighborhood, suggests David Tseng, executive director of Parents, Families and Friends of Gays (www.pflag.org) in Washington, D.C. Be polite, respectful and curious to learn about others in a healthy and constructive way. It's important to recognize that your unspoken response influences your children as much as your spoken one.
**Sometimes, you may disapprove of the family structure of one of your children's classmates. Mark Merrill, president of Family First, a non-profit research and communications organization (www.familyfirst.net) headquartered in Tampa, Fla., defines a family as any relationship of marriage, blood or adoption - but he limits that to heterosexuals. At the same time, he recognizes the reality of gay families. His response: "We are supposed to love everybody." And love, in Merrill's book, is not an emotion that leaps unsummoned from the heart. It is a decision to treat others, even those whose lifestyles you don't accept, with kindness and thoughtfulness and serve them in ways that are best for them.
**Make a concerted effort within your own extended network of work colleagues and of friends to focus less on those who are like you and more on the diversity. "You want to be clear and deliberate about letting your kids know that this is America, this is the diversity of it and not to make a big deal of it," says James Morris, former president of the American Association for Marriage and Family Therapy (www.aamft.org) and assistant professor of marriage and family at Texas Tech University in Fredricksburg.

Experts Try Fast-Track Fix for Children With Phobias
Randi Hutter Epstein, New York Times- 1/20/2004

Bugs ruled Brandon Howard's life as long as he could remember. One glimpse of a beetle flitting by was enough to send Brandon racing away from his buddies to the safety of home. But no more. A single three-hour treatment session turned Brandon, who was 10 then, into a friend of beetles. In this intensive exposure session, a therapist helped Brandon bond with a red-striped beetle and conquer his fears. So far he's been phobia-free for nine months.
      Brandon, who is now 11 and lives in Dublin, Va., is one of 120 children participating in a trial sponsored by the National Institute of Mental Health that is testing a speedy cure for childhood phobias. So far, investigators, from Virginia Tech and Stockholm University in Sweden, claim a 75 percent cure rate — with follow-up of about a year. The concept is a CliffsNotes version of traditional exposure therapy: the people with phobias are exposed to their worst nightmares until their bodies are too weary to respond with stress. But in this trial with children, the lessons typically experienced over several sessions are conducted in three hours. Brandon said he looked at the beetle in the jar for 20 seconds and needed a break. "It was awful at first," he said. And then, in the course of a few hours, he got closer and closer until the bug was creeping up his arm. "It was just amazing how you can really heal and not even know it."
      Children's phobias include fear of strangers among infants, fear of monsters and fierce animals in toddlers and fear of thunderstorms and bodily injury among older children. While some experts believe most children will grow out of these phobias without treatment, others see the need for intervention.
      For parents, it is best to be calm and not allow children to avoid particular phobias totally, many experts say, because that can reinforce the child's worries. And what can seem like an inconvenience often creates havoc in a household when youngsters refuse to go to school, play with friends or go on family outings. Parents talk about children who obsess over weather reports, lose sleep over the possibility of a fire alarm, or refuse to walk to school for fear of encountering a dog.
      Ann Goettman, a mother of three in McLlean, Va., said her formerly outgoing 8-year-old suddenly became terrified of thunderstorms. "It completely changed her personality and disrupted family life," Ms. Goettman said. "She didn't want play dates in case it rained. I'd get calls from the school nurse saying my daughter has stomach pains and I'd have to ask, `Did you hear thunder?' She was constantly checking the weather map to see if there was a lightning bolt in the picture. It consumed her life." Ms. Goettman's daughter, who did not want her name used, suffered from a common phobia. Her fears faded within five months without professional help, but with a lot of reassurance from her parents.
      What type of treatment will work often depends on the child. Some experts question whether children have the courage or stamina to withstand a single intense session, as Brandon did. "One treatment session might be good for the highly motivated child," said Dr. Tamar Chansky, director of the Children's Center for O.C.D. and Anxiety in Plymouth Meeting, Pa. "But I think the message for parents is that you have to know your child. Is your child a microwave or a crockpot? Some kids need more time to stew and simmer. And that's O.K."
      Most therapists prefer a more relaxed pace, teaching a child to behave differently or think differently over several weeks or months. Still, the institute study's focus on phobic children is helping pave the way for a biologically based concept of emotional development. Some scientists speculate that phobias are set off by faulty brain chemistry, creating an exaggerated response to, say, a loud noise or a big dog. But instead of a fix-it-all pill, some authorities are looking to cognitive and behavior therapy to fix faulty circuitry and help children cope with stress better when they grow into adults.
      Kim Howard, Brandon's mother, said her son had been "creeped out by everything since he was 3." "We live in a rural community with all kinds of weird bugs," she said, "but when all the kids were playing, he'd just wind up coming home and doing stuff by himself because of a bee, spider, insect, whatever." By the end of his treatment at Virginia Tech, Brandon's former nemesis, a bean-size box elder bug, became his new pet. "The really weird thing about the whole deal," Mrs. Howard said, "is that he used to be petrified of the dark and thunderstorms. I don't know how it all ties together but he is a different, more confident kid. And there was no hypnosis, no medication."
      Dr. Thomas Ollendick, one of the investigators and a professor of psychology at Virginia Tech, said the "notion is that a phobia persists because a person has certain catastrophic thoughts about what will happen." "We expose them to the fear and help them realize what they dread will happen does not truly happen," Dr. Ollendick said. He and his collaborator, Dr. Lars-Goran Ost, a professor of psychology at Stockholm University, presented preliminary findings on Nov. 23 at the meeting of the Association for the Advancement of Behavior Therapy in Boston. Therapists say the phobia often has nothing to do with the triggering event. Any crisis for the child, like the birth of a baby sister or moving to a new home, can bring on a fear that may seem to have nothing to do with the initial situation.
      In Freud's day, no surprise, psychotherapists believed the fears of toddlers and young children represented unconscious sexual urges. Little Hans, one of Freud's patients in 1909, developed anxiety over horses after a bad fall. According to Freud's analysis, the horse phobia was a reflection of repressed sexual urges for his mother and aggression against his father, said Dr. Allan Compton, a Los Angeles psychiatrist. In the 1920's, Dr. John Watson, a professor of psychology at Johns Hopkins University, argued a radical new theory that phobias could be taught. Dr. Watson based his notion on a flawed study of one boy, Little Albert, who was conditioned to fear rabbits. The researcher claimed he startled Albert by clanging on an iron rod every time he handed the boy a white rat. Like a Pavlovian response Albert would be startled by any white furry creature. A close rereading of the study years later, though, revealed that Albert was never really afraid of rabbits, but the facts did not get in the way of a new scientific paradigm. Dr. Watson's theories formed the basis of a school of psychology known as behaviorism.
      The most recent thinking, said Dr. Diane Findley, an associate research scientist at the Child Study Center at Yale, is that children are born with certain fears and that they can learn not to be afraid. What's more, Dr. Findley added, most therapists today do not believe that digging into the psyche to reveal the root of the problem is necessary for effective treatment. "We worry less about what we think triggered the phobia but about how we can counteract it," said Dr. Romy Engel, a child psychologist, in New York. "I think it's important that they learn effective strategies to cope with their excessive fear. We are not trying to teach them to get fear out of their lives but excessive fear that gets in the way of their functioning."
      Dr. Chansky considers phobias a "mechanical glitch" in the brain, prompting an "exaggeration of risk plus an underestimation of the ability to cope." In her book "Freeing Your Child From Anxiety: Powerful, Practical Strategies to Overcome Your Child's Fears, Phobias and Worries," to be published in March, Dr. Chansky refers to her phobic patients as "what-if" kids — as in, "What if I see a dog? What if it thunders?" Dr. Chansky instructs children to generate two "what elses" for every "what if." In essence, she is telling them to create a new story in their heads, which she believes fixes faulty brain wiring. "You can't be in two feeling states at the same time," she writes. "When a different emotion competes with fear, it chips away at the fear and your child feels less anxious."
      Dr. Ollendick, the researcher in the one-session cure, believes that children's brains are so malleable they can be taught new thought patterns and break the cycle of fear in one session. He concedes, however, that the session is not easy for a child and that not every phobia can be dealt with in a room. Thunderstorms, for instance, have to be simulated. Sometimes, he added, focusing on one fear can help children overcome all of their fears because "they develop a sense of mastery and control."

One of our psychiatry residents smiles and leans against the wall. A woman, a few years younger, stops filling the mailboxes with pens and sheets of paper advertising a new antidepressant and faces him squarely. Her voice is melodic and bouncing. Her eyes open wide and she laughs at something. He smiles. He moves to scratch his cheek and she makes the same movement, they are scratching in unison now. They remind me of a flirting couple on a first date. He has completed medical school and is in the second of four years of psychiatric training. Assuming all goes as planned, in a few years he will be licensed as a psychiatrist. When he starts practicing independently he will write thousands of prescriptions every year; he already writes hundreds. She is "detailing him," teaching him new uses for her company's antidepressant. My office sits just outside the mailboxes and I've been watching her. She's been lurking, slowly filling the mailboxes. He is the third resident she has "detailed" in an hour.
      Our psychiatry department at the University of Arizona is divided over these interactions. On one hand, a number of professors and a few residents have grown concerned that the department is allowing the pharmaceutical industry to teach our residents to embrace newer, more expensive drugs. On the other, many residents have argued against restrictions, suggesting that they should learn to respond to the marketing now and that prohibiting contact would leave them unprepared for the future. A minority have argued that academic freedom gives the faculty and residents the right to speak with whomever they choose. There have been debates in a grand rounds forum, in faculty meetings, and in the weekly resident lunch. In response, our department head recently formed a committee to draft a new policy governing relationships with the pharmaceutical industry.
      Drug company representatives are a major presence. They sponsor Journal Club (where trainees learn to review new data and research), they pay for many of our weekly speakers and regularly offer free dinners for the residents and faculty. They enjoy free access to our mailboxes and regularly detail our trainees in their offices, hallways and in our little kitchen.
      This is not uncommon. Meredith Rosenthal at the Harvard School of Public Health reported in The New England Journal of Medicine that the industry spends roughly $15.7 billion annually marketing medications, with $4.8 billion dedicated to detailing individual physicians, or roughly $6,000 to $11,000 a doctor a year. Studies indicate that most physicians meet with pharmaceutical representatives four times a month. Studies also reveal that most physicians erroneously believe the representatives do not influence prescribing habits.
     When doctors and trainees meet with reps, they change their prescribing habits and are far more likely to prescribe the drugs described, even when they are more expensive or have no benefit over alternatives. They are also more willing to request illogical changes to hospital guidelines that govern which drugs can be prescribed. Estimates suggest that roughly $1 billion was spent advertising antidepressants to health professionals in 2000.
      More than 400 psychiatrists were asked by Dr. Timothy Peterson and his colleagues at Harvard to describe their beliefs about antidepressants. More than half said they believed that newer agents were more effective than older antidepressants known as tricyclic antidepressants and that newer antidepressants, called selective serotonin reuptake inhibitors, or S.S.R.I.'s, had fewer side effects than generic S.S.R.I.'s. But studies conducted at Oxford, Duke, the University of Manchester and the Canadian Coordinating Office for Health Technology that used a statistical strategy called meta-analysis to combine the results of hundreds of independent studies found that S.S.R.I.'s were as effective as tricyclic antidepressants or slightly less effective. They also revealed that S.S.R.I.'s were tolerated by slightly more patients but had as many side effects.
     In an 2002 article, Dr. Peterson wrote: "Despite the lack of evidence of a significant difference in efficacy between older and newer agents, clinicians perceive the newer agents to be more efficacious — these findings are significant as they highlight the discrepancy between empirical evidence and clinical practices and suggest that other factors influence clinicians' medication choices in the treatment of depression."
      The effect is easy to see in our department. The antidepressants fluoxetine, known popularly as Prozac, and paroxetine, known as Paxil, are now generic and cost patients and insurers pennies a day. Newer, rival drugs including sertraline (Zoloft), escitalopram (Lexapro) and Venlafaxine (Effexor) are 5 to 20 times as expensive. In the last seven years, I have watched our residents prescribe the newest medications almost exclusively.
      While doctors' prescriptions are based on more than efficacy and cost — they must also consider potential drug interactions, lethality of the drug if overdosed, the patient's prior history and patient preference — the abandonment of older medications by our residents cannot be justified given available data.
      Programs that limit contact between industry and trainees do result in changes in behavior and attitudes. In 2001, Dr. Brendan McCormick of the University of Toronto and his colleagues published a study in The Journal of the American Medical Association. The research compared internal medicine residents at McMaster University, who were prohibited from meeting with drug representatives during training, with trainees at the University of Toronto, across town, who had no such limitations. After training, when they were free to meet with whomever they chose, the McMaster trainees had less contact with company representatives and were less likely to find such contact helpful.
      In 1999, in response to growing concern in academic medicine, most pharmaceutical companies voluntarily adopted American Medical Association policies restricting lavish gift-giving to doctors. Some training programs went further, developing strict policies that limit access to medical students and residents. Policies adopted by the University of Michigan, the University of Iowa and and New York-Presbyterian Hospital, among others, have restricted pharmaceutical sponsorship of educational activities, have limited or completely eliminated their representatives' contact with trainees and have restricted gifts and where they can be displayed. Unfortunately many programs have failed to address the issue.
      In his Pulitzer Prize-winning book for 1984, "The Social Transformation of American Medicine," Dr. Paul Starr, the Princeton sociologist, argued that doctors won legitimacy during the early 20th century by aggressively taking on charlatans who offered cures and remedies. At the time, the American Medical Association argued that only doctors were objective enough to evaluate the benefits of competing medications. While there were other factors, the association leveraged physician objectivity to garner greater independence in practice, higher salaries and the legitimacy doctors have enjoyed since. If medical schools are unwilling to separate trainees from pharmaceutical company representatives, we risk the appearance of being "bought and sold." This is sure to lead to governmental regulation and greater erosion of independence. And it should.

Last year, the federal government gave doctors who work with heroin addicts a new tool when it approved a drug that blocks withdrawal symptoms. Now a small new study has found that a single shot of the drug, which has few of methadone's drawbacks, can be effective for as long as six weeks, opening the prospect of making heroin treatment far more flexible. The study was published this month in the journal Drug and Alcohol Dependence.
      Methadone stops an addict's craving for heroin, but has been subject to abuse because it can create a high itself. As a result, its use has been generally restricted to clinics that require a patient to show up every day. The new drug, buprenorphine, does not produce euphoria, even when taken in large doses, and it is more effective at blocking the effect of other opiates. Those qualities led the Food and Drug Administration to approve its use more widely, raising the possibility of treating patients in the offices of their own doctors.
      In the new study, five addicts fresh from daily heroin use were given what the researchers called a "depot" formulation of buprenorphine. The drug is contained in tiny biodegradable capsules that float in fluid that is injected; the capsules slowly disintegrate, releasing small amounts over a period of weeks. During four weeks of residential treatment and two weeks of outpatient follow-up, the patients reported few withdrawal symptoms and only mild reactions to injections of an opiate given once a week to test buprenorphine's power to block other drugs.
      An author of the study, Dr. George E. Bigelow of the Johns Hopkins University School of Medicine, said that the long-lasting form of the drug would have "less potential for diversion or abuse."

N.H. Mental Health Bill Gets Panned
Anne Saunders, Associated Press- 1/20/2004

CONCORD, N.H. -- Without community-based services for the mentally ill, many more people would be hospitalized and many more families would suffer, advocates for the mentally ill said Tuesday. Dozens of people lined up to testify Tuesday against a bill that would take away the state's ability to fund many community-based support services for the mentally ill. "I've not been hospitalized in over two years because of this support," Tracy Bleyler told the Senate Health and Human Services Committee. Bleyler said she is able to live independently because she gets help finding work and managing her medication among other things. David Bedell said he suffers from post-traumatic stress disorder and the services enable him to care for his child as a single father. "A few years ago, I was not able to do that."
     The proposed legislation would repeal a law that allows the Department of Health and Human Services to provide care for people with mental illness who are not deemed severely mentally disabled. This includes prevention, emergency referrals, consultation and education, particularly for children and the elderly. Many feared they or their loved ones would have few alternatives to institutionalization if support services disappeared. "This is why you have a crowd here," said Rep. Joe Manning, R-Jaffrey. "This scares the bejeezus out of people."
     Health and Human Services Commissioner John Stephen said his intent was not to eliminate support services but to get legislators to set the priorities for such services. "What are the services we should be funding?" he asked the committee. "I think it's important that the policy be set by the Legislature." The law gives him too much discretion in spending a shrinking sum of money, he said. But not all legislators agreed. Mental health is an evolving field with new therapies and medications, Sen. Jane O'Hearn, R-Nashua, said. Legislators expect commissioners and their staffs to have the expertise to set priorities, O'Hearn said.
     Many of those who testified wanted to know why Stephen was proposing to stop support services when a commission was appointed last year to examine mental health services statewide. Stephen serves on that commission. No one should eliminate any services until that study is complete, argued Sam Adams, president of the National Alliance for the Mentally Ill of New Hampshire. Stephen said he proposed the repeal, to go into effect in July of 2005, to put legislators' feet to the fire. Without a deadline, he feared legislators would not come up with guidelines for providing support services, he said after the hearing. "The department has no intention of reducing our commitment to serving those with mental disabilities," he said.

Paying Attention To Parents Of ADHD Kids
Matt McMillen, Washington Post- 1/20/2004

     The parents of a child with attention-deficit hyperactivity disorder (ADHD) should be tested for the condition themselves soon after the child's diagnosis, the authors of a new study conclude. The study, which was conducted by University of Maryland researchers and published in the December issue of the Journal of the American Academy of Child & Adolescent Psychiatry, found that parents of children who have ADHD are more than 20 times more likely to have ADHD than parents whose children do not. And if their children also have other serious behavioral problems, the study says, the parents' risk for other psychological disorders, such as depression, anxiety and substance abuse, is as much as five times the norm.
     Why the need to quickly identify parents of recently diagnosed children? "It's critical to have parents performing at their best," says Andrea Chronis, director of the ADHD program at the University of Maryland and the study's lead author, "so that the child can perform as well as possible. . . . But if a child has ADHD and the parents do, too, you can imagine the difficulties." ADHD, which affects an estimated 3 to 7 percent of school-age children, often continues into adulthood. The inability to organize and to pay attention, two hallmark symptoms of the disorder, can cause parents to miss their child's doctor's appointments, forget to give the child medication and fail to stick with a treatment plan. Parents with disorders such as depression and anxiety, says Chronis, tend to be withdrawn and irritable; they laugh and smile less, and engage less with their children. Such problems, she writes, "likely contribute to reciprocal patterns of negativity between parents and children."
     The study involved 98 children ages 3 to 7 who had been diagnosed with ADHD and 116 non-ADHD children of similar age. The mother of each child was interviewed to determine whether she and/or the child's father had a history of ADHD, depression, anxiety, substance abuse or antisocial personality disorder. Fathers were not interviewed. According to the study, 0.9 percent of the mothers in the control group met the criteria for having had ADHD as children. Among mothers of ADHD kids, 16.7 percent had had ADHD symptoms themselves. (The study did not assess whether they continued to meet the diagnostic criteria as adults or whether they had been diagnosed or treated for ADHD as children.) Markedly high levels of other psychological disorders were noted among the parents whose children had ADHD, especially those whose children also had accompanying behavioral problems such as opposition defiant disorder (ODD) and conduct disorder (CD).
     This finding was not surprising to several experts on ADHD. "Disorders tend to go together in individuals and families," says Stephen Faraone, clinical professor of psychiatry at Harvard Medical School and author of "Straight Talk About Your Child's Mental Health" (Guilford Press, 2003). "Co-morbidity is the rule rather than the exception." Why? According to Faraone, part of the answer lies in the genes. ADHD, he says, is one of the most heritable disorders in psychiatry: If you have ADHD, he says, it appears there's a 20 to 50 percent chance that you will pass it along to your child. The disorders that often travel with it -- depression, anxiety, substance abuse -- also have a strong genetic component.
     But genes aren't destiny: "If the parent has a gene for alcoholism or depression or antisocial personality, the child is at risk for those," says Faraone, "but it doesn't mean the child will get that disorder. . . . Genes play a substantial role, but they may need to be triggered." One trigger, he says, could be exposure to a parent's depression or alcoholism: "The additional chaos caused by a parent's disorder will increase the chances of getting the disorder."
     Despite strong evidence that a disorder in one family member is a strong predictor of disorders in other family members, treatment traditionally focuses on the individual rather than the family as a whole. This study is "a clear sign that a very comprehensive assessment of the family is needed," Faraone says. "A pediatrician is a very busy guy, but it's easy to ask some questions about the parents' past history of mental disorders, drinking, etc."
     A simple paper-and-pencil test filled out in the doctor's waiting room could go a long way toward determining the parent's need for a complete evaluation, says Russell Barkley, a professor at the Medical University of South Carolina and author of "Taking Charge of ADHD, Revised Edition" (Guilford Press, 2000). "It's not rocket science -- any nurse or office secretary could tally the score," he says. Yet such assessments remain rare: "There are time limits due to managed care, but really it is the ignorance of clinicians that prevents them from getting this on their radar."
     James Perrin, professor of pediatrics at Harvard Medical School, agrees. "We don't do that as well as we should," says Perrin, who co-wrote the ADHD diagnosis guidelines for the American Academy of Pediatrics. When a child is being evaluated for ADHD, says Perrin, pediatricians should be asking the parents about the entire family's history of mental disorders. Often they don't because they don't have the time: "This is not a simple diagnosis," he says. "The way we pay for services, it's hard to get reimbursement for the kind of time necessary to gather information." Spend enough time with the family, though, and the diagnostic information often surfaces, says John Pleasant, a licensed clinical social worker with the Family Group of Washington. "You look for it in certain ways, asking questions like 'How come Billy is missing appointments and medications?' " Responses would likely reveal much about the parent's problems. Pleasant says he makes time to work with the parents as well as the child to address problems that both may be having, but he admits that the time he is able to give is often not enough. "Is the child shortchanged when you address the parent? You do what you can in one hour."
     Patrick Kilcarr finds in his counseling practice that most parents are upfront about their problems if they are asked. "What happens when your son is just staring at his desk?" Kilcarr, who is also the director of Georgetown University's Center for Personal Development, asks parents. "What are your responses? Anger? Frustration?" The answers help him evaluate the parents' need for treatment, something he says that many parents don't expect: "The parent is really showing concern for their child, but they hadn't planned on going into their own psyche and patterns. . . . But if we are going to repair the problem, it has to be done on all fronts."
     A parent of a child with ADHD has to be an "advocate for that child -- attending and scheduling school meetings for example," says Kilcarr. "You need energy in reserve to organize. If you are too scattered or depressed to do that. . . ." Or as Pleasant puts it, "Parents have to be stable enough to deal with things." That means addressing their own problems as well as their child's. If they don't, Pleasant says, "their kid will have trouble being on board about accepting his or her own diagnosis and treatment. I see that all the time."
     In Kilcarr's view, parents and children who address their problems simultaneously can greatly enrich their relationships: "When you have a parent going through change, it becomes a partnership," he says. If the child is at least 11 or 12 when this occurs, he says, "it can be an amazing partnership."
     Chronis, the report's author, is now at work on two studies of mothers with ADHD. "Do treatments for the parents improve functioning?" she asks. "Does it improve the ability to parent?" One study, funded by McNeil Consumer and Specialty Pharmaceuticals, will focus on the effectiveness of the company's stimulant medication Concerta. Eli Lilly & Co. is considering funding research by Chronis on Strattera, Lilly's non-stimulant drug for ADHD. Does this signal a trend away from focusing simply on the child and toward taking into account the entire family? Maybe.
"Just identifying the index patient might not be sufficient," says Calvin Sumner, a senior clinical research physician at Lilly who has studied ADHD for 30 years. "Address the environment. Optimize the environment. That has not been a priority, but we are moving toward this."

Putting Psychoanalysis Itself on the Couch
A.O. Scott, New York Times- 1/21/2004

Psychoanalysis, Janet Malcolm once wrote, is the wary (ultimately weary) examination by patient and analyst of the patient's behavior toward the analyst. Out of this absurdist collaboration - the tireless joint scrutiny of the patient's reactions and overreactions to the analyst's limited repertory of activity in the sphere of fees, hours, waiting-room etiquette and above all absences - come small, stray self-recognitions that no other relationship yields, brought forward under conditions of frustration (and gratification) that no other relationship could survive.
     At its best "Empathy," a curious hybrid of documentary, fictional feature and graduate school seminar paper written and directed by Amie Siegel, elaborates on this insight with something like Ms. Malcolm's skeptical reportorial sensibility. It does not quite reverse her emphasis on the patient's experience of transference but rather points its scrutiny in the other direction, toward the mysterious figure of the analyst himself. And I do mean him.
     The most interesting sections of "Empathy," which opens today at Film Forum, are interviews with analysts, all of them white, male and over 55. Their own musings on the therapeutic relationship - variously coy, candid, thoughtful and self-justifying - are prompted by Ms. Siegel's questions, which are by turns self-consciously sophisticated and deliberately naïve. Do they ever lie to their patients? Have they ever fallen in love with patients? Have the patients, who seem to be as normatively female as the analysts are male, ever fallen in love with them?
     These sessions are layered with the story -- as meandering and inconclusive as analysis itself -- of Lia (Gigi Buffington), a voice-over actress who is being treated for depression. We follow Lia through her desultory routines, which include recording the narration for a documentary within the film on the intersection between psychoanalysis and modern design, with special attention to the shrink-beloved Eames chair. We also see Ms. Buffington and other actresses auditioning for roles in the movie.
     Saying that "Empathy" combines fictional and documentary techniques is a bit misleading, since it deliberately confuses them. In one very funny deadpan scene, Ms. Siegel confronts Lia's analyst (David Solomon, who really is one) in the garage outside his office and starts peppering him with questions, which he refuses to answer on ethical grounds. When the director reminds him that Lia is a fictional character, he replies that it makes no difference; the rules of doctor-patient confidentiality still apply.
     One wishes that Ms. Siegel had held that strictly to the traditions of intellectual rigor and narrative coherence. They also are part of the psychoanalytic tradition, in Freud's case studies for instance, and also in Ms. Malcolm's journalistic observations of his legacy. "Empathy" sometimes feels like a long exercise in free association, wandering from one notion to another without bothering to explicate its ideas or to dramatize them.
     The director's seriousness and intelligence are evident, but so is her satisfaction in displaying them, and the movie has a self-indulgent, undisciplined tone that nearly obscures its provocative ideas about how ordinary life, even at its most banal, is made up of a series of intricate performances and highly complex relationships. I would say more about this, but unfortunately our time is up.
EMPATHY
Written, directed and edited by Amie Siegel; director of photography, Mark Rance; produced by Mr. Rance and Ms. Siegel. At the Film Forum, 209 West Houston Street, west of Sixth Avenue, South Village. Running time: 92 minutes. This film is not rated.
WITH: Gigi Buffington (Lia), Dr. David Solomon (Psychoanalyst), Aria Knee (Anne), Maria Silverman (Rachel) and Jennifer Scott James (Gigi Buffington).

Our Sexual Identity Has Little to Do With Sex Organs
Joanna Schaffhausen, ABC News- 1/22/2004

     Is it a boy or a girl? It's the first question most parents ask about their newborn baby. But for a surprising number of infants, the answer is not immediately obvious. Doctors say as many as 1 in 2,000 babies is born with ambiguous genitalia - neither totally male nor female. For parents, the decision about how to proceed is often agonizing, and the stakes are high: the wrong choice could trap a little boy inside a girl's body or create a girl who longs to be a man. Now a new study in the New England Journal of Medicine is shedding more light on what factors make us feel male or female. The research examined 16 genetically and hormonally male babies born with a rare birth defect called cloacal exstrophy (unlike cases where the genitalia are ambiguous, male babies born with cloacal exstrophy have a small or non-existent penis).
     Traditionally, doctors believed that without a penis, these children would not be able to form a healthy male sexual identity. So, 14 of the 16 babies were assigned the female sex, given female hormone treatments and raised as girls. But follow-up questionnaires given years later suggest that the female label did not stick very well. "These children were born male in nearly every respect," explains study author Dr. John Gearhart, professor and chair of pediatric urology at Johns Hopkins Hospital in Baltimore.

The Key? Hormones
     Gearhart found eight of the 14 subjects now declared themselves male. All 16 of the children enjoyed typical "male" pursuits such as baseball, football, and hockey. Only one played with dolls, and most rejected feminine clothing. The study illustrates what was once unthinkable - that a person can feel like a male without a penis - is completely possible, maybe even predictable, given what we now know about how sexual identity is formed. Hormones are key. "What we now know is that hormones imprint your brain," explains Dr. Craig Peters, a urological surgeon at Children's Hospital in Boston. "We don't know exactly when it happens, but probably even in utero."
     Studies like Gearhart's have helped change policy. Now male babies born with cloacal exstrophy would be recognized as male. "One very seldom does gender conversion for this condition anymore," Gearhart says. Yet surgery for other conditions, especially those involving ambiguous genitalia, is still common. "Probably the most common condition for gender conversion is male pseduo-hermaphroditism," Gearhart explains.

So How Do Parents Decide?
     Parents and doctors have a variety of scientific tools to tell aid them in determining a baby's sex if the genitalia are ambiguous. Genetic testing is performed to check for the presence of a "Y" chromosome. Males are XY; females are XX. An internal exam determines the shape of the pelvis and checks for the presence of female sex organs like ovaries and a uterus. Physicians evaluate whether the person has the potential to be a fertile male or fertile female. Doctors also check the baby's levels of male hormones (called androgens, like testosterone) and female hormones (such as estrogen). In each case, the sex hormones are created by the gonads - testes for males and ovaries for females.
     But production of hormones is only half the battle. The body must have receptors that sense the presence of the hormones or sexual characteristics will not develop normally. Babies who are born genetic males but lack sensitivity to male hormones are sometimes born with ambiguous genitalia, and often the decision is made to raise them as female because treatment with female hormones is considered more successful. A surgeon shapes the genitalia into female sex organs.
     At Johns Hopkins Hospital, they have a "gender committee" that meets whenever an intersex baby is born. The team is headed by a pediatric endrocrinologist, but also contains a surgeon, a social worker and a clergyman among others. Together with the parents the team evaluates the baby and decides upon the best course of action. What is "best," of course, is still under debate, but Gearhart hopes the increased attention to the issue of sexual identity will help future kids caught in the middle. "These long-term studies provide better science for the younger generation," he says.

Intersex Group Calls Surgery 'Mutilation'
     Not all those born with ambiguous genitalia are happy about surgery that alters their sex. An organization called Intersex Society of North America, or ISNA, is devoted to educating people about intersex individuals, and they are challenging the way doctors treat intersex babies.
The group contends surgery can damage a person's sexual function for life. The patient may lose feeling in his or her genitals and be unable to have normal sexual relations. Some intersex individuals even call the surgery "mutilation." ISNA recommends letting the patient decide whether or not to have surgery, which means waiting until a child is old enough to make such a complicated decision.
     But many physicians believe it would be more harmful to wait, and worry about the impact of growing up intersex in a world unprepared to deal with such variety. "I've had parents say, 'I can't stand changing the diaper,' " Peters says. But ISNA argues it is society's job to adjust to intersex individuals and recommends counseling for families and patients dealing with the issue.
     While Gearhart praises ISNA for raising awareness about intersex issues and pushing doctors to rethink their positions, he adds, "Initial studies from Hopkins are finding that most intersex people don't support the idea of a third gender." Notes Peters, "A lot of the adults complaining about the surgery is based on old technology. We didn't know as much then, and surgeons would do things like cut away the entire clitoris. Surgery has improved a lot over 20 years ago."
     But some surgeons find merit in ISNA's message. "It's rare that an enlarged clitoris would cause any medical problems, so we have time to wait," says David Vandersteen, pediatric urologic surgeon and vice-chief of surgery at Children's Hospitals and Clinics of Minneapolis/St. Paul. "Gearhart's study suggests that the relationship between external genitalia and psycho-social development is moderate at best, and shows there is good psychological foundation for leaving well enough alone."
     Another point of debate is what and when an intersex child should be told about his or her medical history. In Gearhart's study, the children and young adults still living as females have not been told about their male genetic status.
ISNA favors telling kids as much as they can digest while they are still very young. Doctors are less sure about the timetable. "A lot of bitter adults are bitter because they were never told," Peters says. "I believe kids should know but I don't know when. Finding out this information as a teenager would be difficult."

GAO: OxyContin Claims Unsubstantiated
Associated Press, 1/22/ 2004

WASHINGTON -- The maker of OxyContin sent doctors promotional videos that made unsubstantiated claims minimizing the dangers associated with the pain relief drug, congressional investigators said Thursday. The General Accounting Office also said that in 1998, Stamford, Conn.-based Purdue Pharma failed to submit one of the videos to the Food and Drug Administration for review, as required, when the company started circulating it to thousands of doctors. The company said its failure to send the video to the agency was an oversight. It did submit a 2001 video for FDA examination, but the agency did not review it ``because of limited resources,'' the report said. On the 1998 video, a doctor says less than 1 percent of people who take pain relief medication like OxyContin become addicted. That's a figure the FDA says has not been substantiated, the report said. The FDA looked at the later video after GAO investigators inquired about it. The agency said it ``appeared to make unsubstantiated claims regarding OxyContin's effect on patients' quality of life and ability to perform daily activities and minimized the risks associated with the drug.'' The FDA also publicly cited Purdue Pharma last year for overstating OxyContin's safety in print ads.
     OxyContin was initially hailed as a breakthrough in the treatment of severe chronic pain when it was introduced in 1996. The drug has become a problem in recent years, however, after users discovered that crushing the time-release tablets and snorting or injecting the powder yields an immediate, heroin-like high. Lawmakers asked GAO, the investigative arm of Congress, to study Purdue Pharma's marketing of OxyContin because of the drug's widespread abuse, especially in Appalachian states. The drug's potency may have made it an attractive target for abuse, the report said, and a safety warning advising patients not to crush tablets because of the rapid release of a drug component may have tipped abusers off about how to misuse the drug. The report said it was difficult to pinpoint the relationship between the increase of OxyContin prescriptions in recent years and the diversion of the drug to abusers, because data on drug abuse isn't reliable.
     Purdue Pharma spokesman Jim Heins said that lack of information about why the drug has been abused means critics shouldn't point fingers at the company without obtaining more proof. ``There's not a clear indication that our marketing has led to diversion and abuse,'' Heins said. ``Unfortunately, prescription drug abuse has been a problem in the U.S. for a long time, particularly in Appalachia.' Heins confirmed that Purdue Pharma is facing roughly 340 lawsuits for its marketing of OxyContin, but he said 70 of them have been dismissed.
     Republican Rep. Hal Rogers, who represents an eastern Kentucky district hard-hit by OxyContin abuse, is among the lawmakers who called for the investigation. Rogers said one thing that upset him was the report's finding that the company didn't analyze physician prescribing reports, which the company regularly uses for marketing purposes, to identify possible abuse of the drug until 1999. That was three years after reports of widespread abuse surfaced. ``Why did it take the company three years to use their highly detailed data on physician prescribing practices to identify patterns of abuse?'' Rogers asked.
     The GAO investigators recommend that the FDA encourage drug makers to submit plans to the agency identifying potential problems for abuse and diversion of new drugs. FDA spokeswoman Kathleen Quinn said the recommendation is similar to one made by an advisory panel. ``FDA does agree with both that committee's recommendation and GAO's in their encouragement of stronger risk management plans,'' Quinn said. ``We are working to put those types of plans in place.''
     On the Net:
General Accounting Office: http://www.gao.gov/
Purdue Pharma: http://www.pharma.com/

More Cases Test Mental Health Workers
Laura Potts, Detroit Free Press- 1/22/ 2004

Working through lunch hours, in the evening and on days off is nothing new for mental health workers. But with an increasing number of cases, some say the burden has become unbearable.
Mental health workers say more caseloads mean less time for therapy sessions and slower progress for people with severe mental illness. Additionally, limited funding means some people may not be getting any help.
     But in Macomb County, mental health workers and county officials are working toward a solution, scheduling regular meetings to give updates on the caseload situation. Their next meeting is Friday, and caseworkers say they already see progress toward improving mental health care and lightening the load by referring some clients to other agencies. "The biggest impact has been on the workers. They will not allow the clients to be harmed, so they have sacrificed themselves," said Donna Cangemi, a therapist for the Macomb County Community Mental Health (CMH) agency and president of the American Federation of State, County and Municipal Employees Local 411.
     The number of people receiving mental health services actually dropped slightly in Macomb County and statewide from 2001 to 2002, the latest available data show. According to the Michigan Department of Community Health, Macomb County provided mental health services to 6,819 people in 2001, and 6,564 in 2002; Michigan served 135,964 people in 2001 and 131,192 in 2002. But mental health officials attribute that decrease to reduced funding, not fewer people needing services, and say the number of workers also has fallen, because of layoffs and unfilled vacancies. That means the remaining workers are handling more cases.
    With Michigan facing a possible $900-million deficit, there are no new dollars for mental health services. "Hopefully, the answer for us is that the economic recovery eventually comes. But I can't see anything happening immediately," said Patrick Barrie, deputy director of mental health services for the Department of Community Health.
     Though numbers are not yet available for 2003, mental health experts believe more people started seeking services, particularly in later months, as economic troubles hit home. Not only did that contribute to clients' heightened stress and anxiety, experts said, but they saw more indigent clients and people who lost private insurance and turned to the public health system.
     Cangemi, who works part-time, said she has 22 clients. Full-time therapists she works with have upward of 100 -- double the ideal number of cases for adequately treating clients, Cangemi said.
"There are a lot of services when you have 95 clients that are difficult to do," including therapy sessions and helping to improve daily living skills, she said. "Those are the kinds of services sometimes we have to compromise when we have as many cases as we have."
     Macomb County social workers fear that when coworkers retire, the caseloads will double. And with the time-consuming paperwork that accompanies each client, workers can't spend as much time helping them become more stable and productive.
     CMH officials don't dispute that workers are overburdened and that caseloads are rising. Susan Doherty, a Macomb County commissioner, said the paperwork that caseworkers must complete is "incredibly burdensome." And Jim Wargel, CMH division director of behavioral health and network operations, said officials are assessing the number of workers and looking for solutions to ease the caseloads. But with limited funds, CMH must find new ways of helping caseworkers balance the services they provide. One option is to seek help from other agencies, such as the Family Independence Agency, said Maxine Thome, executive director of the National Association of Social Workers, Michigan chapter.
     In Macomb County, mental health workers are being encouraged to refer some clients to other service providers that contract with the county, Wargel said. That has started to decrease the number of cases workers handle, Cangemi said, and is an encouraging step for workers.
But Cangemi said she hopes solutions can be found for mental health workers across the state, who are facing similar dilemmas.